scholarly journals Restructuring service at a mastology outpatient clinic during the COVID-19 pandemic

2021 ◽  
Vol 74 (suppl 1) ◽  
Author(s):  
Cristina Poliana Rolim Saraiva dos Santos ◽  
Ana Fátima Carvalho Fernandes ◽  
Denise Montenegro da Silva ◽  
Régia Christina Moura Barbosa Castro
Keyword(s):  
Patient Safety ◽  
Electronic Medical Records ◽  
Outpatient Clinic ◽  
Medical Records ◽  
Healthcare Services ◽  
Public University ◽  
Telephone Contact ◽  
Health Team ◽  
Individual Assessment ◽  
Surgical Treatments

ABSTRACT Objective: to report the experience of a health team in restructuring service at a mastology outpatient clinic. Methods: an experience report in a public university service mastology outpatient in Ceará between March and April 2020. Service in this outpatient clinic is exclusively for women and who have breast changes for surgical treatments ranging from nodulectomies to mastectomies with oncoplastic. Results: increased COVID-19 cases brought the need to restructure healthcare services. The following steps were followed: identification of scheduled patients, reading of clinical developments in electronic medical records, individual assessment to define whether or not appointment would remain, telephone contact to inform about unscheduling. Among the 555 consultations scheduled for March and April 2020, 316 (56.9%) were maintained. Final considerations: restructuring consultations at a mastology outpatient clinic optimized the waiting time for consultations and avoided crowds at service, providing patient safety.

scholarly journals IT-CARES: an interactive tool for case-crossover analyses of electronic medical records for patient safety

2016 ◽  
Vol 24 (2) ◽  
pp. 323-330 ◽  
Author(s):  
Alexandre Caron ◽  
Emmanuel Chazard ◽  
Joris Muller ◽  
Renaud Perichon ◽  
Laurie Ferret ◽  
...  
Keyword(s):  
Patient Safety ◽  
User Interface ◽  
Adverse Events ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Medical Procedures ◽  
Odds Ratios ◽  
Hand Column ◽  
Case Crossover ◽  
Interactive Tool

Background: The significant risk of adverse events following medical procedures supports a clinical epidemiological approach based on the analyses of collections of electronic medical records. Data analytical tools might help clinical epidemiologists develop more appropriate case-crossover designs for monitoring patient safety. Objective: To develop and assess the methodological quality of an interactive tool for use by clinical epidemiologists to systematically design case-crossover analyses of large electronic medical records databases. Material and Methods: We developed IT-CARES, an analytical tool implementing case-crossover design, to explore the association between exposures and outcomes. The exposures and outcomes are defined by clinical epidemiologists via lists of codes entered via a user interface screen. We tested IT-CARES on data from the French national inpatient stay database, which documents diagnoses and medical procedures for 170 million inpatient stays between 2007 and 2013. We compared the results of our analysis with reference data from the literature on thromboembolic risk after delivery and bleeding risk after total hip replacement. Results: IT-CARES provides a user interface with 3 columns: (i) the outcome criteria in the left-hand column, (ii) the exposure criteria in the right-hand column, and (iii) the estimated risk (odds ratios, presented in both graphical and tabular formats) in the middle column. The estimated odds ratios were consistent with the reference literature data. Discussion: IT-CARES may enhance patient safety by facilitating clinical epidemiological studies of adverse events following medical procedures. The tool’s usability must be evaluated and improved in further research.

Perspectives on Electronic Prescribing and Terminologies

2013 ◽  
pp. e370-e373
Author(s):  
David Liebovitz
Keyword(s):  
Patient Safety ◽  
Electronic Medical Records ◽  
Medical Records ◽  
International Classification Of Diseases ◽  
Population Based ◽  
Electronic Prescribing ◽  
Medication History ◽  
Diagnosis Codes ◽  
Classification Of Diseases ◽  
Potential Benefits

Electronic medical records provide potential benefits and also drawbacks. Potential benefits include increased patient safety and efficiency. Potential drawbacks include newly introduced errors and diminished workflow efficiency. In the patient safety context, medication errors account for significant patient harm. Electronic prescribing (e-prescribing) offers the promise of automated drug interaction and dosage verification. In addition, the process of enabling e-prescriptions also provides access to an often unrecognized benefit, that of viewing the dispensed medication history. This information is often critical to understanding patient symptoms. Obtaining significant value from electronic medical records requires use of standardized terminology for both targeted decision support and population-based management. Further, generating documentation for a billable encounter requires usage of proper codes. The emergence of International Classification of Diseases (ICD)-10 holds promise in facilitating identification of a more precise patient code while also presenting drawbacks given its complexity. This article will focus on elements of e-prescribing and use of structured chart content, including diagnosis codes as they relate to physician office practices.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals Challenges with Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height

2021 ◽  
pp. 48-57
Author(s):  
Elizabeth Kukielka
Keyword(s):  
Patient Safety ◽  
Lung Function ◽  
Creatinine Clearance ◽  
Body Surface ◽  
Outpatient Clinic ◽  
Reporting System ◽  
Healthcare Services ◽  
Safety Reporting ◽  
Dosing Error ◽  
Unit Of Measurement

An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.

scholarly journals Prawidłowe prowadzenie dokumentacji medycznej jako warunek bezpieczeństwa pacjenta w procesie leczniczym

2021 ◽  
Vol 44 (1) ◽  
pp. 24-42
Author(s):  
Magdalena Gąska ◽  
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Medical Records ◽  
Treatment Process ◽  
Healthcare Services ◽  
Record Keeping ◽  
Applicable Law ◽  
The Impact ◽  
The Way

This article discusses the impact of the proper medical record keeping on ensuring patient safety in the process of providing healthcare services. The study presents the principles of keeping, processing, storing and ensuring the access to the medical records resulting from the applicable law and established jurisprudence views, as well as the way in which these guarantees affect the protection of such sensitive patient interests as health, life and privacy. The article also indicates the areas in which the patient's right to medical records is the most frequently violated and the trends in this regard, as well as it formulates postulates aimed at increasing patient safety in the treatment process.

Management of demographic equality of access to family intervention for psychosis in specialist community mental healthcare teams

2021 ◽  
Vol 27 (8) ◽  
pp. 1-11
Author(s):  
Pawel D Mankiewicz ◽  
Jordan Reid ◽  
Eleanor Anne Hughes ◽  
Angelica Attard
Keyword(s):  
Electronic Medical Records ◽  
Medical Records ◽  
Mental Healthcare ◽  
Family Intervention ◽  
Healthcare Services ◽  
Subsequent Treatment ◽  
Record Keeping ◽  
Bonferroni Adjustment ◽  
Treatment Uptake ◽  
Equality Of Access

Background/Aims UK mental health services must provide evidence-based psychological treatments, including family intervention, to every service user diagnosed with psychosis. Although healthcare managers are required to ensure equitable delivery of prescribed core treatments, in practice equality of access remains debatable. This study investigates equality of access to family intervention for psychosis. Subsequent treatment uptake and engagement are also examined. The role of healthcare records in equality management is considered. Methods Retrospective analysis of electronic medical records of 244 service users across four specialist early intervention teams in London in 2018 was undertaken using binary logistic regression and multiple linear regression. Bonferroni adjustment was applied to control for type 1 errors. Results Participants were found to have equal access to the nationally endorsed treatment across all demographic variables. Likewise, treatment uptake and engagement were equally distributed. Conclusions An overall compliance with national policies was shown, demonstrating that equal provision of core treatment for psychosis is achievable. As discrepancies in record keeping were shown to impede the data extraction process, suggestions were made for the management of electronic medical records in mental healthcare services.

scholarly journals Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care

2017 ◽  
Vol 7 (2) ◽  
Author(s):  
Munish Sharma ◽  
Mahesh Krishnamurthy ◽  
Richard Snyder ◽  
James Mauro
Keyword(s):  
Renal Function ◽  
Patient Safety ◽  
Electronic Medical Records ◽  
Clinical Pharmacist ◽  
Medical Records ◽  
Therapeutic Response ◽  
Adverse Drug Events ◽  
Point Of Care ◽  
Bleeding Diathesis ◽  
Dosage Error

The incorporation of a clinical pharmacist in daily rounding can help identify and correct errors related to anticoagulation dosing. Inappropriate anticoagulant dosing increases the risk of developing significant bleeding diathesis. Conversely, inappropriate dosing may also fail to produce a therapeutic response. We retrospectively reviewed electronic medical records of 41 patients to confirm and analyze the errors related to various anticoagulants. A clinical pharmacist in an integrated rounding between the period of February 2016 and April 2016 collected this data. We concluded that integrated rounding improves patient safety by recognizing anticoagulant dosage error used for the purpose of prophylaxis or treatment. It also allows us to make dose adjustments based on renal function of the patient. We think that it is prudent for physicians to pay particular attention to creatinine clearance when dosing anticoagulants in order to achieve the intended dosing effect and reduce the risk of adverse drug events.

Electronic medical records in a cardiological outpatient clinic

2003 ◽  
Author(s):  
M.A. Morales ◽  
S. Dalmiani ◽  
C. Carpeggiani ◽  
A. Macerata ◽  
S. Ghione
Keyword(s):  
Electronic Medical Records ◽  
Outpatient Clinic ◽  
Medical Records
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