Case Study: Adverse Trends In Health Care

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In today’s health care system, it is imperative to have data accessible to the members of the health care team in real time. In the case study that was presented a patient was tested for methicillin-resistant Staphylococcus aureus (MRSA); the lab results were negative however, the lab record was updated as the patient being positive for MRSA. It was found that this was the third time that lab results were uploaded to the wrong patient’s EHR record from the emergency room. We are going to look at the adverse trends and how it impacts patient care when the wrong lab results are posted to an EHR. In this paper we will discuss how adverse trends may occur and how to investigate them further using the decision-making process to make informed changes in the way that we utilize information technology and other tools throughout the continuum. Adverse events can be traumatic for both the patient and the staff that are involved (Vincent, 2003); in this situation a patient was wrongfully placed in contact precautions. …show more content…
Adverse events “pose considerable challenges to an organization, both in terms of the need to respond intelligently to their occurrence and in terms of the need to deal with their aftermath” (Vincent, 2003, p. 1051). In the above-mentioned case study, the wrong chart was update to have MRSA, meaning that the patient that actually had MRSA in their urine was not placed in appropriate precautions. Therefore, increasing the risk of exposure and the spread of MRSA to employees caring for the individual who has MRSA. It is important to take a closer look at the trend data available to determine what is causing the errors in the lab results being placed on the wrong chart when a patient is admitted through the emergency department. When evaluating the root cause of an adverse trend, it is important to collect and review the following data including the “sample size”, “presence of extreme observations or outliers”, “availability of numerator and denominator data”, and confounding which “changes over time in factors related to the indictor of interest” (Trend Analysis and Interpretation, 1997, p. 6). In this particular situation, the sample size would be the patients admitted through the emergency room with labs during a month period. A data collection tool is a “device created for the purpose of accumulating specific details in an organized fashion” (Hebda & Czar, 2013, p. 577). In this individual scenario standardized reporting modules would be a way to obtain the discrete data list of patients seen. Once the data was available, it would be important to note if there were extremes or outliers, in this example if there were one lab tech was working for the emergency room when the errors occurred; this would give a starting point to examine what the causes behind the errors might be. By having access to the employee schedules from both departments you would be able to assess if there is a correlation between who is working verses an EHR or technological error. It would be important to interview the employees that were working during the time frames of the noted errors, to know what their process is for sending and receiving laboratory results from one department to the other through the EHR. The numerator in this case would be errors that occurred in the transmission of lab results to the patients chart in the EHR; the denominator would be the total of patients seen in the emergency room that had lab work drawn or collected. The final piece …show more content…
One suggestion would be to implement a policy that states that all lab results must have the patient identifying information readily available on all patient reports throughout the hospital; this would prevent issues from occurring on other units as well. Another suggestion for immediate correction would be to create a standardized procedure for the reporting of laboratory results for patients who are admitted through the emergency room. After standardizing the policies and procedures, all staff must be provided education on the new process. I would recommend having department meetings for all of the departments throughout the hospital. By having this educational meeting, members of the individual units would be able to express their concerns regarding the new process and allow for clarifications that might be necessary in the implementation of the new

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