Data accessibility is a necessity in the health care system. “Data management is the process of controlling the collection, storage, retrieval, and use of data to optimize accuracy and utility while safeguarding integrity” (Hebda & Czar, 2013, p.65). Nursing informatics has changed the accessibility of data and decision-making process. Nursing Informatics is the “science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide” (IMIA Special Interest Group on Nursing Informatics 2009). Technology has changed the way information is collected and shared. Interoperability allows to entities computer or human to share data while not changing and maintaining the original meaning data. This paper will discuss how adverse trend may occur and why to investigate further. The data needed to collect, the source, and why that data is needed. List of description of data collections methods, how the data affects the adverse trend, explain how the use of technology is used, and a description of the regulatory factors.
Adverse trends lead to severe medical errors. A trend that frequently occurs is inconsistency of patient’s knowledge of the dosages or names of their home medications. Frequently on admission when questioning patients they do not recall the name of the medication or dosage. Patient’s that are on methadone need to maintain their dose to decrease with draw symptoms knowing the dosage is important. After reading and learning about other hospitals and having a mater patient index that gives a complete view of the patient’s history. Developing a master patient index that had interoperability to communicate with other pharmacies and clinicians. Master patient index is a database that lists all identifiers to one patient using all information systems. Using this system would allow access to all patient information. Having access to all patient information would allow you to see the current medications and dosages the patients are taking.
This access increases patient safety. In order to initiate a master patient index program the data that would be needed is patient first and last name, social security number, birth dates, and driver license number. Information needed goes beyond demographic information and social security number. Creating a master patient index can decrease errors, view patient history, increase time efficiency, and improve accuracy. Through the master patient index accessing patient medications from pharmacies allows nurses to know the current medications patient’s are taking, and increasing safety. There are many issues of safety acknowledging medication allergies, and contraindication of medications with current medication. The master patient index is highly security, business integrity and confidential.
As in any facility HIPPA is the only legal issue. Accessing patient’s records should only be on a need to know basis. Hospital staff that access patient’s record that should not are reprimanded according to the facility hospital. The increasing change in technology has allowed for data accessed at a finger touch. The increasing access can help save a patient life. Data management is helpful in decreasing medical errors, quicker documentation, increasing patient safety, and assist in decision-making process. Data management can assist in recognizing trends, and help create a new nursing process. Master patient index would create a current record of patient’s history for all facilities to view. If a patient came into the hospital unable to speak accessing their health record the master patient index would allow physicians to view the patient medications, allergies, vitals, and retrieval patient’s visits.
Hebda, T., & Czar, P. (2013). Handbook of Informatics for Nurses & Healthcare Professionals (5th ed.). : Pearson Education, Inc. Sewell, J., & Thead, L. (2013). Informatics and Nursing: Opportunities and Challeges (4th ed.). Philadelphia, Pennsylvania: Wolters Kluwer Health | Lippincott Williams & Wilkins. http://www.amia.org/programs/working-groups/nursing-informatics