Uses of Statistical Information

Uses of Statistical Information

One of healthcares top challenges today is capturing, updating, and managing a tower of patient information. Integrated clinical and management information systems have proven to be an enormous advantage in improving decision making in an in-patient hospital setting and thus creating a single resource for integrated patient information. This information gathered can assist the practitioner in patient care by analyzing, trending, and graphing patient outcomes. Data gathering occurs at all different levels within the in-patient facility and is responsible for current and future policies and procedures.

Vital statistical information is gathered and retrieved for numerous reasons with a few being maintenance of licensure, malpractice retention, and medication errors. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently changed its name to The Joint Commission to coincide with its new and improved mission to better improve the quality and safety of patient care. The Joint Commission set high standards to tackle the level of performance provided by various organizations. The statistical data gathered is disseminated in the form of quality reports. The reports were created to compare statewide information on a national level and to force organizations into developing and promoting effective polices and programs. The Joint Commission has set the standards and provided the solutions for organizations to maintain its accreditation while responding to the very issues that influence the health care industry (Joint Commission, 2006).

Type of information collected

As noted in the article Medication Reconciliation, "clinicians and healthcare organizations have come to understand the critical role that medication errors - inadvertent and usually preventable - play in jeopardizing patient safety"(Clancy, 2006). To assist with the reduction of errors a process called medication reconciliation has been initiated within the in-patient care setting. The Joint Commission's sentinel event database reports that 63% of medication errors resulting in death or major injury were at least in part a result in breakdowns in communication, and approximately half of those would have been avoided through effective medication reconciliation. The core recommendation includes adopting a systematic approach to reconciling medications, starting with reconciling at admission. The use of a standardized form is encouraged to communicate patient's medication to the next level of care or provider within or outside the organization

Medication reconciliation is a process that involves three specific steps. Those steps are required to prevent dangerous medication errors. The medication reconciliation process involves verification, clarification, and reconciliation. These three steps allow for the systematic review of all patients' home medications, both prescribed and over the counter, prior to hospitalization medications, medications that were prescribed during the hospital stay, and medications to take upon discharge.

The Joint Commission has started an initiative requiring all accredited hospitals to decrease their medication errors. For hospitals to start this undertaking they first must collect data and review where their current gaps in their medication statistics stand and start data collection on the changes they have initiated with medication reconciliation. To understand the issues and needs hospitals must start to gather data on medication errors and their outcomes. This process has been in place for the majority of facilities, but in-depth research and statistical analysis in most facilities was never placed as a top priority.

The methodology needed to initiate this project would be to set up two different study groups and compare the data from both groups. The relative frequency or empirical method could be used for this data gathering. One group would be patients that did not have the reconciliation process in place; the other group would be patients which had a reconciliation process at some point in their hospital stay. A chart review of both groups would be done and the number of mistakes documented and compared. After the review, the frequency of the discrepancies would be presented and changes implemented based on the findings. This research and data would then aid in the change of policy and decrease in patient medication errors.

Error Reporting

Error reporting is encouraged by managers and administrators; however, there are still many barriers to reporting near misses. If healthcare workers are uncertain about what constitutes a close call and when to report it, many real and potential problems will remain unrecognized by management. There is no opportunity to identify and correct latent and overt flaws in the system, or assist individuals whose practice fails to meet acceptable standards of professional conduct. The definition of a near miss is closely tied to the evolving concept of error. In the past, healthcare professionals usually relied on evidence of actual patient harm before considering the possibility that an error had occurred.

In a recent study, healthcare professionals discussed error as a deviation from written standards of practice. In the absence of proof that an explicit standard of care or practice guideline was violated; some study participants simply attributed the unanticipated adverse event to an "act of God." Research in the realm of patient safety has broadened the definition of error. The Institute of Medicine defines error as the failure of a planned action to be completed as intended, or the use of a wrong plan to achieve an aim. The definition would include actions that do no necessarily result in patient injury, and include events labeled as close calls or near misses. Some experts in the field of patient safety prefer to call near misses good catches, emphasizing the positive aspects of error identification and the resultant prevention of harm. Good catches imply vigilance, awareness, critical thinking, prompt action,