Active Health Records in Acute Setting

Active Health Records in Acute Setting

Surgery is one area of health care in which preventable medical errors and near misses can occur. However, until the 1999 Institute of Medicine report, To Err Is Human, clinicians were unaware of the number of surgery-associated injuries, deaths, and near misses, because there was no process for recognizing, reporting, and tracking these events (Mulloy, 2008). Active Health Records in Acute Setting
The 2015 article written by Nwosu describes two cases from a Nigerian trauma center in which wrong-site surgeries were performed. In case one, a 75-year-old female was injured in a traffic accident. She sustained a central right hip dislocation with an acetabular fracture. During the procedure, the surgeon performed a reduction of the left hip with pin placement. Upon reevaluation, it was discovered that the surgery was performed on the incorrect extremity. Case two involved a 43-year-old bus driver following a traffic accident unable to bear weight bilaterally. Radiographs revealed bilateral femur fractures and a left tibial fracture. Neither incident was officially reported to the hospital for review. Upon analysis of both cases, the surgeon’s inexperience does not play a role in wrong-site surgery error. The factors identified as causes of wrong-site surgeries include distraction, incomplete preoperative assessment, and insufficient patient information in the operating room, policy issues, and the lack of operating room checklists (Nwosu, 2015). In my opinion, both cases were due to a lack of attention to detail and a lack of teamwork and communication, specifically in the second case study. The anesthesiologist brought his concerns to the surgeon’s attention several times without a “time-out” to regroup and ensure the correct procedure was performed. Active Health Records in Acute Setting



The Joint Commission (TJC) publishes yearly National Patient Safety Goals. These goals are designed to improve patient safety. The goals focus on problems in health care safety and how to solve them. The 2021 safety goals include several goals, including identifying patients correctly, improving staff communication, using medicines safely, using alarms safely, preventing infection, identifying patient safety risks, and preventing mistakes in surgery (, 2021). Although all these goals are essential, we will focus on preventing mistakes in surgery for this discussion.
There were two programs described in the article implemented to improve hospital patient safety. The Joint Commission introduced the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery in January 2003. The Universal Protocol applies to all surgical and non-surgical invasive procedures. Evidence indicates that procedures that place the patient at the most risk include general anesthesia or deep sedation, although other procedures may also affect patient safety (, 2021). Hospitals can enhance safety by correctly identifying the patient, the appropriate procedure, and the procedure’s correct site. The Universal Protocol is implemented most successfully in hospitals with a culture that promotes teamwork and where all individuals feel empowered to protect patient safety. The Universal Protocol is based on the following principles (, 2021):
• Wrong-person, wrong-site, and wrong-procedure surgery can and must be prevented. Active Health Records in Acute Setting
• Using a multiple and complementary strategy to always conduct the correct procedure on the correct person at the correct site.
• Active involvement and the use of effective methods to improve communication among all members of the procedure team are essential for success.
• Patient and family involvement in the process, as much as possible.
• Implementation of a standardized protocol is most effective in achieving safety
Another program designed to reduce surgical errors was the World Health Organization (WHO) Surgical Safety Checklist. The checklist consisted of “sign-in, time-out, and sign-out.” The protocol also promotes safe anesthesia, teamwork, and the prevention of surgical infections (Nwosu, 2015). Unfortunately, in many parts of Africa, Asia, and Europe, as of 2015, the TJC “Universal Protocol” and the “WHO Surgical Site Safety Checklist” were not being utilized.
The registration process must be both accurate and efficient. Failure to meet both of these goals can lead to adverse outcomes.Active Health Records in Acute Setting   Slow registration can hinder care by delaying the processing of orders of tests or delaying access to existing medical records and, in the long run, not providing adequate emergency care (Hakimzada, 2008). Inaccuracy in gathering information can lead to errors, including lack of access to existing medical records, inability to contact a patient after discharge, and even implementation of an incorrect treatment regimen with dangerous consequences to the patient’s safety.
Biblical integration: John 15:12, “My command is this: Love each other as I have loved you.” God loves us in an incredible way. It’s up to us to find ways to bring that love into our community.  Active Health Records in Acute Setting

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