Safety Topic of the Month: EHR Documentation and Workflow Safety

Quality | Safety | Service

By Karen Radabaugh, Clinical Informaticist

Safety is Patient-Centric

Early in my career as a clinical informaticist, my main goal was to help create an electronic health record (EHR) that made the role of the clinician easier. With the assistance of a very wise mentor, I came to understand that our goals should be patient-centric, not clinician-centric. The EHR is designed is to improve the care given to the patient. No one intends to practice unsafely, but the current culture of short staffing, downtimes and high census often tempts the clinician to take shortcuts and use workarounds.

Error Prevention Tips to Remember

Bar Code Medication Scanning (BCMA)
BCMA may take more time, but it can prevent errors. Do you bar code scan every medication you can? Do you report medications that do not scan and scanners that do not work? Do you have a questioning attitude? If you receive an alert or warning, do you investigate and not blow past it to save time?

Use of CPOE prevents communication and transcribing errors. Our CPOE rates are lower than they should be and leadership has made this a top safety concern. Do you promote the use of CPOE and ask providers to place their own orders when possible? If you have to take a telephone order, do you input it in Cerner while you are on the phone? Do you use Read Backs when taking an order? If you receive an alert, do you notify the physician?

Medication Reconciliation
Inaccurate Medication Reconciliation is one of the top contributors to medication errors and another top safety concern. Studies show over 50 percent of patients have at least one unintended discrepancy in their medication list and harm to the patient often occurs due to this discrepancy. MedRec is not just the filling out of a form, it requires critical thinking. Medication Reconciliation is a provider’s responsibility, but the nurse can follow some simple steps to keep our patients safe. Do you do a thorough medication history? An accurate medication history is the backbone of safe MedRec. Cerner carries forward the medication list from the last admission, but the nurse is still responsible for reviewing that list for accuracy. Do you do this review? Do you pay attention to detail and question anything that seems off?  

Lab Specimens
Improper identification of specimens can be prevented with the use of proper workflows. Are you labeling the specimen in the room? Are you scanning the patient armband and label?

Planned PowerPlans
PowerPlans are an important tool that can increase the quality of care for our patients. PowerPlans are planned so they can be initiated at the proper time. If they are not initiated, important medications, tests or other treatments are often missed. Do you know how to check for planned PowerPlans? There are four places in Cerner to view Planned PowerPlans (Orders screen, Care Compass, Patient Handoff, and the report PowerPlans in a Planned State). It is a requirement to review for planned PowerPlans with each 12-hour chart check. If a patient has a planned PowerPlan, do you know when it should be initiated? If not, contact the provider for clarification. Remember, if unsure whether to initiate, communicate!

The intent is for the EHR to be available at all times. However, there are times, both planned and unplanned, that the system is down. When information is not readily available and workflow processes are interrupted, the patient is at risk. The best way to keep our patients safe during this time is to know your downtime procedures. Do you know what your downtime procedure is? It is located in your downtime binder? Is it kept up to date? Do you know where your downtime viewer is located, where to get the password, and how to sign on? If not, learn these now! Do not wait until you are in a downtime to familiarize yourself with the process.

Timely Entry of Information
One of the most important benefits of the EHR is to provide the right information to the right person at the right time. In order for this to happen, the information has to be entered in a timely manner. There are features (and more to come very soon) that monitor the patient information and provide alerts to providers and clinicians. These alerts cannot work if the information is not in the system. Do you enter your vital signs immediately after they are taken? Do you dock your glucometers after performing tests? Do you document your assessments as soon as possible? Documentation in a timely manner is an essential part of having an efficient EHR.

This is only a sampling of examples of the benefits but also the risks of an EHR. CHI and the Clinical Informatics team are working to improve the safety of the systems you use. You can help by practicing safe workflows, educating yourself on the proper way to use the EHR, and reporting issues that make the workflow inefficient or unsafe.