Practical/Clinical Issue. Reply 2

The purpose of this post is to discuss a quality/safety issue that I have seen in my clinical setting. I will begin with a brief discussion of Quality and Safety Education in Nursing (QSEN) competencies.

QSEN has six competencies that were developed to help future and graduate nurses to enhance their knowledge and skills to ensure that they can facilitate the delivery of high-quality and safe care. They are also supposed to assist nurses and nursing students to develop an attitude that helps them identify gaps in healthcare as well as help shore these gaps to continuously improve the safety and quality of the healthcare systems (American Association of Colleges of Nursing, n.d.).

I have identified a quality issue with the informatics at my clinical setting that has the potential to not only impact quality of healthcare provided but safety as well. Informatics is the utilization of information and technology to communicate, direct knowledge, assuage error, and assist with decision making (AACN, n.d.).

Why is this an issue?

There are several issues that I have identified, one, the medication prescription system is not user-friendly. Often, the provider cannot find the exact strength of medication they are looking for (even if it exists) and sometimes must use a combination of drug strengths to arrive at their desired dose. This is risky because it requires entry of multiple prescription strengths, and a higher or lower dose may be ordered in error.

Second, there are protocols such as the requirement for psychiatric providers to do a baseline Abnormal Involuntary Movement Scale (AIMS) test on any person over 65 years old on antipsychotics and repeat this test every 6 months. However, the system does not flag these patients to notify the provider of this important test and there is also no flag to act as a reminder to do the test when it is due. As a result, some patients are missed for up to 1.5 years. This is dangerous because, when the AIMS is not performed every six months or as needed, there is a risk that symptoms of tardive dyskinesia (TD) will be missed resulting in delayed intervention and or worsening (Johnson, 2017).

Third, the prescription platform is not linked to any online resources that can guide a provider in decision making such as Medscape, UpToDate, Epocrates, Beers criteria, etc, or allow one to review them. In fact, to check or verify any information, you must completely disconnect from the system. It is a 2-portal system and thus re-logging back on is time-consuming and leads to inefficiency. While a provider should be knowledgeable of medication, its uses, effects, and side effect, and interaction, the human mind cannot simply know it all. As such, it is important and safer if the provider is able to double-check themselves with verified and evidence-backed resources.  These have been shown to potentially improve preventive interventions, diagnosis, and management of disease (Gordon et al., 2020; Kim et al., 2017).

What are the potential negative outcomes that can arise if the issues are not resolved?

As noted above an inefficient medication prescription system exposes the patients to medication errors which is both a safety and quality issue (Kim et al., 2017). Also, the work involved in trying to figure out medication dose equivalents or dose additions wastes precious time that the provider could be utilizing for more suitable actions and exposes them to an increased risk of making prescription errors. Second, the inability of the documentation system to capture patients that require an AIMS as well as flag those that require a repeat AIMs poses a risk for missed diagnosis of TD in patients which is a safety concern. Third, a system that hinders the utilization of available and EB resources for providers to review their med choices/information interferes with safety as providers opt to go ahead and order the medication and review later. Also, providers are not able to access new and upcoming information on medication and conditions that could influence their decision making and management of the patient (Gordon et al., 2020; Johnson, 2017).

In summary, the issues discussed above have been raised by a few providers and the medical director in conjunction with the IT department and their prescription software builders are working to try to resolve these issues. I am glad to report that the director does perceive these problems as both safety and quality concerns and is inclined to see them resolved sooner than later. I also think that as a future novice PMHNP, I will make sure to ask about the competency of an organization’s informatics as I now realize the importance of working for an organization that works to empower its providers to provide high-quality and safe care. I will also inquire about reimbursement for applications like Epocrates, UpToDate, DynaMed Plus which can be utilized on a handheld mobile device to faster access. However, I would be careful with the use of apps as they often change and update. Resources such as The American Psychiatric Associations ‘app advisor’ are helpful with EB apps.