Operating in a fast-paced, unpredictable environment, healthcare workers experience greater stress at work and more negative outcomes of stress than professionals in other fields. Medical transcription companies are focused on helping them with their arduous documentation tasks. However, high workload, lack of experience and support systems, medical negligence, miscommunication, and poor collaboration can lead to nursing mistakes. Medical errors pose a threat to patient morbidity and mortality and are a serious and costly public health problem. Let’s take a look at the common areas where errors in nursing occur and how to avoid them.
- Medication administration: According to the National Medication Errors Reporting Program, medication errors kill one person every day in the US. When it comes to medication, nurses shoulder a lot of responsibility as interact directly with the patient, and have to interpret instructions and administer medicine correctly. However, mistakes can occur during the process of dispensing and administering medication such as inappropriate dosage, errors of omission, wrong medication, or wrong route of administration. Taking the following steps can help prevent these errors:
- Using a bar coding medication scanning system to confirm the six medication rights: correct medication, patient, route, dose, time, and documentation
- Actively consulting with the pharmacist and other team members to ensure all look- and sound-alike drugs are stored in a way that they can be distinguished
- Double checking all high-alert medications with another clinician
- Know the medications administered, including adverse reactions
- Informing the patient about the medication administered and the reason for it
- Asking the patient about any reactions or allergies before administering medication
- Ensuring that the patient’s medication list is consistently updated
- Infection: As patients have a compromised immune system, they are susceptible to infections caused by bacteria and pathogens present in hospitals. According to the CDC, approximately 1 in 31 patients has at least one Healthcare Associated Infection (HAI) on any given day. The medical setting needs to be kept clean and healthy by following proper infection prevention protocols. Steps that nurses should take to minimize patients’ risks of infection include:
- Hand hygiene – washing hands frequently and wearing gloves when touching a patient
- Using chlorhexidine for skin preparation to prevent surgical site infection
- Sterilizing and sanitizing equipment
- Following guidelines for central line use and removal
- Cleaning and removing catheters in a timely manner and avoiding long-term catheter use as far as possible
- Following specific checklists to prevent central line bloodstream infections ventilator-associated pneumonia, etc.
- Documentation: With their heavy workload, nurses find it difficult to document major events and changes in patient condition. Charting should be done accurately and in a detailed and timely manner. This is important to ensure that other clinicians have all the information they need to treat the patient. Any adverse events should be immediately reported. In addition to signs and symptoms and healthcare provider notifications, all information given to patients and/or their caregivers should be documented. Handwritten notes should be clear and legible. A medical transcription service provider can provide valuable support when it comes to ensuring high quality EHR documentation.
- Falling accidents: The Agency for Healthcare Research and Quality (AHRQ) estimates that, every year, about 700,000 to 1 million people in the US experience a fall in a hospital. More than one-third of in-hospital falls result in injury, including serious injuries such as fractures and head trauma, according to the agency. Even the slightest fall can result in serious injuries and cause legal problems for the hospital. Patients can fall when they are weak or try to get up and move around on their own after a procedure. The common reasons for hospital falls include negligence by nurses, staff shortage, improperly trained staff, lack of/not following proper patient lifting techniques and hazards like spills, broken tiles or loose rugs. The best way for nurses to prevent patient falls is by constantly checking up on those at a higher risk and making sure that they have everything they need within reach. Hallways, patient rooms, and recreation areas should be inspected regularly for problems that could patient slips and falls.
- Equipment-related injuries: Patients can suffer injuries as a result of the malfunctioning of hospital equipment. MRI, IV pumps, heart monitors, anesthesia machines and mechanical beds can fail they are not working or used properly. Training nurses on proper and safe use of the facility’s equipment can reduce the risk of such equipment-related injuries. Equipment should be used only as intended and properly maintained to ensure it is working well.
Errors and adverse events occur relatively frequently in the complex healthcare environment in which nurses work. According to www.healthmanagement.org, collaboration and mutual trusts among team members is critical to optimize care. Recognizing and reporting errors will help develop systems to prevent mistakes and improve performance. Medical transcription services are a practical strategy to accurate and timely EHR documentation and reduce stress on nursing staff, increase focus on patients, reduce the incidence of medical errors, and optimize care.
