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Introduction
Medication errors are attributed to multiplicity of factors. Some of them are caused by fault lines in the health care system itself or an improper use of medication. The underlying problem in medication errors lies in issues related to medical safety and quality which are left unchecked. Medical records are important storage facilities for patients’ data which are used for current and future medication (Barker, 1992). The safe keeping of medical records is the task of the medical records department. According to Bell (2005), efficiency of the medical records in the administration of patient care at Riyadh Military hospital revealed serious flaws. This paper shall investigate the relationship between medication errors and poor medical records based on empirical evidence of the risks involved.
Scope
The data was collected using specially designed questionnaires with high standards of information confidentiality being maintained. Participants for the feasibility study ranged from nurses, physicians and patients. Their feedback on the impact of medical records in administration of healthcare was useful in assessing relevance electronic methods in record keeping towards eradication of medication errors. Medication errors are investigated at the hospital with regard to the degree to which the risk of improper management of patients’ data leads to poor medical interventions.
The safe keeping of medical records entails the task of compiling, storing, typing and retrieving patients’ data in health institutions (Cherry& Jacob, 2005). Data is documented from different sources at the hospital for the purpose of facilitating ongoing medication to various patients. Patients’ data is not only important in supporting sustainable medication; it also facilitates proper hospital management, clinical research, teaching, reimbursement and meeting legal requirements. Documentation of patients’ data and its retrieval should be efficient in order to ensure professional, quality and timely healthcare is provided to patients. Manual keeping of records from diverse sources at Riyadh Military Hospital is both cumbersome and inefficient.
The handwritten record is the traditional method of medical documentation at Riyadh Military Hospital in tandem with practice in Saudi Arabia (Clark, 2008). The Arab Medical Board also demands that efficient medical records are provided as proof for accreditation of a hospital. Findings from study respondents revealed that faulty features of data entry and management existed at Riyadh Military Hospital. In essence, the system applied in recording medical information at the hospital was outdated and below international standards befitting its status. Access to patients’ data was particularly difficult which also complicated personalized therapeutic interventions.
Efficiency of the medical records department is ascertained through its accessibility, accuracy, confidentiality and accountability. Other important functions measured in evaluating the efficiency of record keeping include the elements of precision, legibility and timeliness of medical data documentation and retrieval. Efficiency also requires that staff working in medical records departments is professionally qualified. Efficient medical record is an important tool for carrying out medical research since it provides empirical data for analysis. Medical practitioners also find properly recorded data useful in provision of healthcare to their patients.
The hospital relies on an efficient database at medical records for planning and organizational management. This informs the need for electronic record keeping since poorly recorded data could distort patients’ historical archives necessary in therapy. Medication errors are also a consequence of erroneous clinical database resulting in loss of resources and lives (Corlett& Wilson, 2005). Due to distorted medical record database, important clinical time is wasted courtesy of uncalled for referrals and improper medical investigations.
Identification of medication error risk factors
Confidentiality of patients’ information was also at stake at the reputable hospital. Confidentiality is highly regarded in the medical profession especially when patients’ data is concerned (Fagin, 2008). According to the feasibility study, the mean scores of data obtained from respondents revealed that leakage of data at Riyadh Military Hospital was rampant. It was quite easy for anyone to access private medical information from the records department as well as other departments at the hospital. Patients are privileged to their medical data whether they are alive or dead. As such, privileged medical information is only accessible to third party individuals through the verbal or written consent from the patient.
The physical security of medical record facilities is of utmost importance in therapeutic interventions. Physicians at Riyadh Military hospital raised complaints with regard to persistent loss of files. The physical space was too small for storage of medical records (Furlong& Milstead, 2006). Approximately twenty thousand patients’ files were congested in a small room. The likelihood of files missing or getting lost was rated as high. Medication errors were therefore likely to increase taking into account the high rate of patient admissions and medical operations at the hospital.
Consequently, health workers at the hospital’s medical records department were in dire need of more training and financial incentives in order to perform their duties to the required standards. It is particularly necessary that workers in this crucial department are trained on effective public relations skills and supervision techniques through continuous education. It is therefore important that training of workers at the medical record department is sustained for greater efficiency, quality and output of patient care at Riyadh Military hospital.
The need for electronic and computerized medical record keeping could not be overemphasized. An electronic medical record not only improves timely documentation of patients’ data but also facilitates access by relevant physicians for purposes of monitoring drug interactions and other therapeutic interventions appropriately (Huber, 2006). However, the task of entering data and subsequent analysis of patients’ information could shift the burden from clerical workers to physicians. This would mean that doctors attend to fewer patients than before which also reduced the quality of patient care. In addition, physicians required further computer training in order to sharpen their typing and data entry skills coupled to their consultancy work.
The presence of desktop computers in doctors’ consultation rooms created a barrier between physician and patients. The important patient-physician relationship may be seriously distracted when physicians record patients’ data electronically. Patient respondents in the feasibility study by Badreldin& Mohamed, complained of diminished quality of medical care in departments where electronic documentation had been exclusively introduced. In essence, physicians divided their time between attending to their patients and recording data on computers. The more the patients, the more cumbersome the tasks became decreasing the quality of patient therapy. Although accurate, the use of software tools in electronic medical records was an exorbitant venture that may also compromise on the relationship between the patient and the doctor (Huston& Marquis, 2008).
The most feasible alternative thus remained effective data management by the medical records department exemplified through continuous education and training. Effective clinical practice requires that medical records and physician consultations become synchronized in order to provide the right data to the right patient at the right time. The lack of proper record keeping at the hospital needs urgent managerial attention in facilitating trainings and equipment that permits appropriate data entry and retrieval.
Risk analysis
Below is the analysis of the risks associated with distortions in medical records and medication errors. The mean scores and percentages illustrate the magnitude of the highlighted risks as calculated from data obtained from the respective respondents.
Table 1: Mean score of respondents about the staff of medical records
Table 2: Mean score of physicians and nurses about medical records department.
Table 3: Mean score of physicians, nurses and patients about the MRD
Table 4: Physicians’ judgment on electronic medical records (EMR)
Risk management process
Establishing the context
Ergonomics is the science that fits workplace conditions and high productivity towards mutual satisfaction of staff and organization (Kelly, 2009). As such, work related factors that could pose risks to the physical, emotional and psychological state of the workforce are assessed in order to alleviate them. Distorted data is thus assessed with respect to the reported cases of missing/lost files order to understand the underlying risk. Policy frameworks should respond to the reported cases by creating alternative safe and healthful working conditions for medical records’ clerks.
Ergonomic efforts should be prioritized when designing policies on occupational health and safety. Ergonomic interventions should be all-inclusive incorporating employees, supervisors and worker representatives in the discussions of the policies in order to ensure their successful implementation (Barker, 1992). The deliberations can be augmented with relevant training on ergonomic risk factors that may predispose physicians and support staff to cumbersome tasks of manual handwritten record keeping at the expense of client care. Effective training should be supported by expertise advice from consultants that should initiate start-up interventions as in-house expertise is being developed.
Corporate government level
The Ministry of Health (MOH) is entrusted with the responsibility of monitoring the operations of all health care providers in Saudi Arabia. The MOH plans, manages, finances and supervises the health sector (Furlong& Milstead, 2006). It also outlines relevant legal policies to govern the operations in the healthy sector through guidelines, standards and missions. Managers are therefore entrusted with the task of providing regulations to all health professionals in the Kingdom in order to guarantee the safety of everyone. They are expected to organize trainings on occupation safety and use of assistive devices/equipment.
The most salient of the strategies for risk reduction lies in the use of peer leaders and positive reinforcement of compliance tradition by managers (Fagin, 2008). Peer leaders have to express their commitment to reduce the risk of confusing medical records practically. This is best done through modeling behavior of their followers by using computer-aided designs themselves in order to encourage clerical officers to follow suit.
Regular Audits are necessary in order to determine the degree of compliance to the use of both handwritten and computer designs in record keeping. Monthly audits are necessary in monitoring the efficacy of the strategies employed and the variation on the data from incident reports. Due to severity of the problem, audits should be consistent, practical and time bound.
Communication strategy to deal with risk
Communicating appropriate guidelines and updates to health workers might be hampered by language barrier since English is a second language to Arabic in Saudi Arabia. Due to the shortage of medical staff in Saudi Arabia, most specialists working there come from different nationalities and culture. Proper implementation of change plans in the hospital with respect to risk management of poor medical records is therefore hindered by culture differentials and language barriers. Majority of the managers and leaders are locals.
Corporate governance at the hospital should ensure that health workers receive further education and training through culturally and linguistically appropriate methods (Lambertsen, 2008). The management can seek the services of an interpreter for patients with limited English proficiency during working hours. Medical records’ staff should develop training through English as an international language. This also facilitates resolution of cross-cultural grievances between the patients and care givers. Communication between the clerks, nurses and physicians is important in facilitating the task of data entry and analysis towards quick recovery of the patients. Client care should be the hallmark of healthcare at the organization. Managers’ participation in risk management is important in motivating foreign personnel (Huston& Marquis, 2008).
Since workload at the records department is ever increasing, clerks do not find time to upgrade their skills through further studies. Employee motivation is therefore important in reducing emotionally-related stress among overworked health workers. The sheer demonstration of the corporate governance in risk management interventions serves to motivate workers with the hope of better compensation and rewards. The presence of motivated and enthusiastic employees promotes skills development and risk management interventions.
Organizational level
Health workers at Riyadh Military hospital are expected to work for 44 hours a week inclusive of the night shifts. However, the intensity of clerical work is magnified by the number of patients and medical activity taking place at the same time. Patients are treated depending on data stored at the hospital. If left unattended, they are bound to suffer health complications or even die. The hospital’s reputation as the leading health institution in the region and beyond depends on the quality of services rendered to its patients. The quality of the services provided corresponds to the degree to which workers are informed about proper documentation methods and ethics. Workers at the hospital’s medical records department should be properly motivated due to the nature and complexity of the tasks.
Organizations and workers are integrated such that they are interdependent (Tate, 1999). Organizations need their employees to work for them towards realization of their objectives. Workers on the other hand expect to receive proper rewards for their efforts and expertise. Employees are therefore the life-blood of the organizations they work for. Motivation should therefore follow performance appraisal regimes and reward systems in order to direct workers’ efforts towards organizational objectives. Workers and their families are properly catered for through an assortment of incentives at Riyadh Military hospital.
Facilities for leisure are provided through a versatile recreation center and other sports amenities located near staff residence. Shuttle buses ferry workers to and from work including the luxury of transporting their children to school and back. Individual employees are privileged to hire limousine cars at a subsidized cost incase their residence is remotely located from the city center where the hospital is located. Appropriate accommodation is provided to both singles and married couples. Salaries are paid monthly in Saudi Riyals whose equivalencies fluctuate depending on the prevailing exchange rates. Workers are also entitled to overtime, holiday and flight allowances. Subsidized meals and educational grants are also advanced to workers and their families in order to motivate them.
The facilities have positioned the hospital as a lucrative employment destination in Middle East and the rest of the world. Riyadh Military hospital is a reputable health facility because of its quality services, staff training and intensive medical research (Huber, 2006). Implications of the missing and loss of patient files could severely damage the quality of service provided to patients at the expense of the esteemed reputation of the hospital in Saudi Arabia and the rest of the world. The problem of bulky patient files should therefore be addressed scientifically in order to prevent the unfortunate event where clerks develop career dissatisfaction.
Evaluating the risk
The vicious cycle of poor record keeping and missing/lost files could lead to prolonged hospitalization of the patients (Shaw, 2007). The continued stay at the hospital results in increased medical expenses upon the patient’s family while the hospital suffers losses due to reduced productivity. Fatalities are also increased due to patients developing health-related complications as a result of the diminished patient care. The ultimate negative implication of the medication errors arises from the loss of the hospital’s reputation as a leading health facility in the region. People are likely to seek for medication in any other hospitals costing the hospital revenue. The process of training new recruits on computerized database filing is a further financial strain on the hospital (Clark, 2008).
Organizational program
Application of electronic medical records should serve to reduce the backlog of huge files in the limited physical space. It should further augment handwritten method of collecting through the safe storage aspect. The underlying challenge lies on the effective compliance of the hospital staff in applying the skills when discharging their duties. Positive reinforcement of compliance among clerks and other hospital staff by the management should be encouraged. This can be achieved through performance appraisals and reward schemes that recognize individual effort. Public recognition of staff who personally works towards practical application of the preventive interventions is appropriate motivation. Money is not the ultimate motivation but should be incorporated as part of the strategy which includes public performance appraisals, promotions and training. Nurses, patients, physician and clerks should also be empowered to express their grievances in relation to their tasks without fear of reprisal.
The standard working day at Riyadh Military hospital takes eight hours. Proper compensation must be extended to clerks who work overtime in order to motivate them on their work. They should express any difficulties related to use of software to corporate governance as soon as possible. The problem requires urgent attention in order to prevent transmitting confidential patient information between different departments. Desirable action should follow technical and professional algorithms meant to arrest the situation early enough (Yoder-Wise, 2003). Riyadh Military hospital is also a teaching and referral health institution. The Ministry of Health and other stakeholders in charge of managing healthcare in Saudi Arabia should develop training of staff at the records department for purposes of capacity building and quality assurance.
Training therefore requires that managers provide necessary ethical leadership based on the practical knowledge on the appropriate interventions. Apart from modeling behavior through the practical use of support software themselves, proper leader-follower ship principles should be applied. Leaders should create a transparent environment for communication and giving feedback between managers and their subordinates. Clerks should be free to express dissatisfaction whenever their working conditions deteriorate. Corporate governance should welcome criticism from their subordinates on such matters as the limited physical space and lack of appropriate support equipment. The clerks, being most affected by the huge files, should be trained on how to give positive and negative feedback relating to the challenges of organizing medical records manually.
Project Team Level
The working group should comprise of about seven to fifteen members preferably the clerks and their fellow support staff. The peer group should be led by one of their members. The group is meant to discuss assessment protocols and ergonomic assessment algorithms with the goal of teaching one another the best techniques in data entry, analysis and retrieval. Work group leaders should be motivated to provide local solutions to any emerging problems with the prospects of being considered for promotions, rewards and recognition by the top management (Tappen, 2008). However, group members should be encouraged to contribute towards ergonomic discussions in an assertive manner without fear of reprisal.
Group discussions should not be occupied by peer leaders alone. According to Huston& Marquis, (2008), work groups should be guided by orderly procedures for identifying problems, collecting ergonomic data, analysis and a framework for developing proposed solutions with maximum support from all the stakeholders. Training is required on the technical aspects of the underlying electronic record keeping. Group members should be trained in communicating feedback, listening to one another and accountability skills. The underlying goals and objectives of the group should be realistic and achievable. The group should therefore seek to solve easier problems before embarking on the complex ones since this motivates group member confidence in the discussions.
Peer leaders are mandated to propose problem solving and conflict resolution interventions while members debate on the appropriate implementation strategies. Role modeling of positive behavior and approaches should be the hallmark of peer leadership (Johnson, 2006). However, leaders should not dictate the course of action upon their followers. Implementation of the appropriate strategy should be left to individual members. The leaders should actually lead through their followers. Both parties should enlighten one another on the need for proper documentation of patient files from time to time. Members should seek to encourage each other through counseling sessions meant to motivate support staff discouraged from handling huge patient files. The group should serve as a source of inspiration to each member.
Individual level
At individual level, workers should be encouraged to report directly to corporate management on the alleged missing/lost files through both formal and informal channels. They should also spearhead relevant campaigns to incorporate workers’ reports and patient suggestions on the underlying problem towards improving working conditions. They may also initiate periodic surveys to obtain feedback that could indicate cases of data distortions or statistics of its reduction. Collected data from worker inputs should be publicized in appropriate newsletters and the hospital’s notice board. Appropriate suggestions should be documented and feedback provided on the effectiveness of the agreed interventions.
Conclusion
Risk management process requires progressive checks in order to guarantee elimination of the conditions that favor recurrence of risks. The problem of poor record management presents far-reaching implications to the entire hospital and the community that depends on it. Patients seek medical care from the hospital with the hope of recovery (Cherry& Jacob, 2005). The hospital’s image and reputation is dependent on the quality of service provided by its staff. The contribution of clerks in provision of healthcare and support to patients cannot be overestimated. Risk management interventions should therefore target all the affected persons especially the support staff at the medical records department.
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