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Through a Memorandum of Understanding with the Department of Health, behavioral health hospitals (BHHs) licensed by the Department of Public Welfare are required to submit reports to PA-PSRS under the Medical Care Availability and Reduction of Error Act of 2002 (Mcare or Act 13). CASE VIGNETTE 1An elderly man with bipolar disorder and a complicated medical history is admitted to inpatient psychiatry in the context of an acute manic episode. CASE VIGNETTE 2A middle-aged man with chronic pancreatitis, diabetes, and polysubstance dependence (alcohol, opioids, and other substances) presents to the pain team for an opioid prescription. For decades, medical specialties such as internal medicine and surgery have engaged in morbidity and mortality (M&M) conferences—but very few in psychiatry. One opportunity to use QI is via systematic and structured reflection on the quality of clinical care. Perhaps the most salient impediment to successful conferences is their association with a culture of blame, bullying, and disrespect. A change in culture will require adjusting expectations to understand that medical errors are not an anomaly.
James Phelps, MD is Director of the Mood Disorders Program at Samaritan Mental Health in Corvallis, Ore. Prescriptions have been obfuscated by a combination of Latin and English abbreviations (sometimes they even throw in Greek words).
Traditionally, a prescription is a written order for compounding, dispensing, and administering drugs to a specific client or patient and once it is signed by the physician it becomes a legal document. Patient Information, which may include information such as name, address, age, weight, height, and allergies. Signature lines, which is where the prescriber provides their signature and indicates their degree.
Prescriber information, which includes the physician's name, practice location address, telephone number and fax number. Refills, which simply indicates how many refills may be supplied for a particular medication. Warnings, which are provided by the prescriber with the intention of emphasizing specific concerns. So, if we look at a prescription for Patricia Pearson (see below), we can see that it is for Lipitor (atorvastatin Ca) 20 mg tablets, and that the patient is to receive 30 of them with 2 refills. Other things of note include the date that the prescription is written for is August 31, 2013.
Besides over the counter medications (OTC) such as aspirin and ibuprofen, behind the counter medications (BTC) such as Allegra-D (fexofenadine with pseudoephedrine), and prescription medications (Rx legend) such as amoxicillin and digoxin, there is another group of medications to be concerned with called controlled substances. A Southern California hospital chain known for its aggressive billing practices and cost-cutting is being investigated by state and federal authorities for an unusually high rate of life-threatening infections among its older patients. Septicemia, or blood poisoning, arises most often in hospitals with poor procedures for infection control. Health and Human Services department spokesman Don White said the federal probe of Prime Healthcare was requested in July by Democratic U.S. The investigations are under way even as Medi-Cal auditors, after a separate inquiry, have flagged Prime for $2.8 million in questionable expenses. In e-mails and interviews, Prime Healthcare officials denied any wrongdoing, saying their company provides excellent health care even as it has engineered the turnaround of hospitals that had been in desperate financial trouble.
Prime Healthcare, based in San Bernardino County, operates 12 hospitals in Southern California and a 13th hospital in Shasta County. Freed from pre-negotiated discounts, Reddy’s hospitals can collect much higher reimbursements for treating insured patients. Reddy can be hands-on about maximizing revenue, a former Prime nurse has claimed in a wrongful termination lawsuit pending in Los Angeles Superior Court. By requiring her to attend the meeting, Reddy led Karwecki to believe her job was safe, she contended, but the following month, she said she was laid off and denied severance pay. Kumar, the reimbursement management director, acknowledged in an e-mail that Prime hospitals have higher rates of septicemia.
Because of this emphasis, and because Prime physicians strictly follow Medicare coding guidelines for reporting the illness, he said more septicemia cases get reported, even though they may be only early, and not advanced, cases.
As an example, he cited the hypothetical case of a 75-year-old stroke victim hospitalized with aspiration pneumonia, respiratory failure and early sepsis. The lure of an extra payment to treat septicemia infections has led some providers to file false claims with Medicare when they had actually treated less serious conditions.
Suspicions of septicemia upcoding at Prime have been fueled by the union, which represents about 150,000 hospital and health-care workers in California. According to a copy of the analysis, Prime’s septicemia rate for fiscal year 2008 was extremely high.
Between 2004 and 2008, the septicemia rate at every hospital in the Prime chain had at least doubled, the union analysts wrote.
In his e-mail, reimbursement management director Kumar said the lower mortality rate is another reflection of the company’s emphasis on treating septicemia.
In May, a state attorney general’s official told the SEIU that its complaint was referred to a Health Care Fraud Task Force. In a letter written in May, Geiger told the union that he was referring the results of the computer analysis to a joint state-federal Medicare fraud task force in Southern California. In July, the lawmakers wrote to the inspector general, asking for an investigation of Prime.
The request could complicate Prime’s effort to add a 14th facility, Victor Valley Community Hospital in Victorville. A spokesman said the health department was gathering information to respond to the lawmakers’ request for a probe of Prime. Regarding the helicopter, auditors reviewed details such as flight logs and maintenance records to determine whether expenditures were related to patient care, as required by state and federal law. Eventually, authorities flagged $491,000 in operating costs related to the helicopter as unjustified.
Finally, the auditors struck out $436,000 in political lobbying expenses unrelated to patient care. General Counsel Michael Sarrao said most of the lobbying expenses flagged by the audit actually were consulting fees. The CEO of Sun sent his employee Julie Campbell to apologize to me in Oct 2003 for harming my mother, 3 yrs later threatened me in mediation. I will attempt to legally have the original settlement rescinded and for Sun to compensate me for the many months of suffering I witnessed my mom endure, as well as her untimely death. I am sorry for what you have gone through .Once again "follow the money" is always destructive in any place these days . I was floored , my son was having tremors right in his doctors arms, and this guy would do nothing,nothing not even give my child the brain scan that he was asked to do by my sons doctors out east . Some of the errors may be more difficult to identify and the item may be valid even if the amount billed for it is not. This template can be easily customized, turning it into an email contact list, an address list or simple phone list. You can add as many columns as you want, so you can use this list for keeping track of birthdays, anniversaries, and even mark which addresses to include on your Christmas card list. The references listed below can help you set up your list for mail merge or importing into other contact list software (like Outlook and Gmail).
Use this template with Microsoft Word's mail merge feature to print form letters and envelopes. Simply save the Contact List Template as a CSV file to get started importing your contacts into other software such as Outlook and Gmail Contacts. Family Tree Template - If you like to keep track of addresses for your family, what about important dates? Science, Technology and Medicine open access publisher.Publish, read and share novel research. Clinical Decision Support Systems: An Effective Pathway to Reduce Medical Errors and Improve Patient SafetyChiang S. Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. 1998 Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. Electronic implementation of guidelines in the EsPeR system: a knowledge specification method.
Involving patients in decision making and communicating risk: a longitudinal evaluation of doctors’ attitudes and confidence during a randomized trial. Computerized physician order entry of medications and clinical decision support can improve problem list documentation compliance. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review. A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. Several patterns have been identified in over 1,200 BHH reports received during the 18-month period from July 2004 through December 2005. Given the patient’s significant improvement in function on opioids, but history of aberrant use, he receives weekly refills from his addiction psychiatrist. Only a handful of academic institutions have incorporated some type of M&M-like experience.
In the Psychiatry Milestone Project, recently implemented by the ACGME, residency training directors are asked to assess resident proficiency and advancement during training in these areas. Unfortunately, these still permeate much of the medical field.6,18 Leape19 described this dysfunctional culture as “a substantial barrier to progress in patient safety,” inhibiting collegiality and cooperation, decreasing communication, undermining morale, and hindering compliance with and implementation of new practices. Instead, they are an inevitable result of imperfect humans performing clinical duties, even when operating to the best of their abilities.
They are commonly used on prescriptions to communicate essential information on formulations, preparation, dosage regimens, and administration of the medication. Use context clues from the rest of the prescription to determine which translation is appropriate.
Prescriptions are required for all medications that require the supervision of a physician, those that must be controlled because they are addictive and carry the potential of being abused, and those that could cause health threats from side effects if taken incorrectly, for example, cardiac medications, controlled substances, and antibiotics. Often, this is also where a prescriber may indicate their preferences with regard to generic substitution. Below is a list of some of the more commonly misinterpreted abbreviations and dose designations.
He declined to identify the source, and investigators haven’t determined whether violations occurred, he said. The spending included payments for the lease on a Beverly Hills home, depreciation on a Bentley sedan, and bills for operating a private helicopter and for stays in upscale Las Vegas hotels.
Henry Waxman and Pete Stark asked for an investigation of alleged Medicare fraud at Prime Healthcare. To save money, the company sometimes suspends services such as chemotherapy treatments and eliminates birthing centers, the Los Angeles Times has reported.
After its 2007 takeover of Centinela Hospital Medical Center in Inglewood, Prime laid off 13 percent of the staff, the Times reported. According to figures provided by the federal Centers for Medicare & Medicaid Services, a provider might be paid between $1,800 and $3,400 more for treating a case of septicemia rather than a urinary tract infection, depending on complications and other factors. Later, a coder trained in medical classification reviews the patient’s file and assigns the appropriate diagnostic code, which Medicare uses to determine reimbursement.
It distributed its computer analysis of national Medicare billing data to state and federal officials earlier this year. Although septicemia at Prime hospitals was triple the national average, the death rate for septicemia patients at Prime was far lower: 38 percent below the national average, according to the report.


The union also took its analysis to Waxman, chairman of the House Committee on Energy and Commerce, and Stark, chairman of the Ways and Means Committee’s Subcommittee on Health. 8, Assemblyman Bill Monning, D-Santa Cruz, who leads the Assembly Health Committee, wrote a similar letter to the health department, also asking for an investigation of alleged upcoding at Prime and a moratorium on new hospital licenses for the chain until the probe is complete.
The company announced plans to acquire the San Bernardino County facility earlier this month. Other disallowed costs identified in the audit included $820,000 for a lease and taxes on the home in Beverly Hills and $303,000 in depreciation for the helicopter and for the Bentley. CEO Lex Reddy, Prem Reddy’s brother, said the helicopter is needed so executives can avoid spending hours stuck in traffic.
Rather, they signify sums that the state will not recognize when compensating the chain for its corporate office expenses. The article is clearly aimed at healthcare workers they are trying lure in with trickery and lies. I am shocked by what appears to be an (allegedly) willful disregard for patient welfare.We don't know what the truth is, but I hope that,for the patients' sake, that this issue is dealt with posthaste. Whether trying to keep track of all your contacts or putting together a phone or address list for a specific occasion, Vertex42's free customizable Contact List Template can help you get organized. Survey assessment of physician’s knowledge regarding benefit contribution from the improvement of clinical documentation by the CDSS. The complex relationships are to connect prescribed medications to ongoing problems in the EMR.
Link medication orders to problems and diagnoses through the associated indications in a network model. The development of an effective CDSS has a significant impact on clinician’s practice plans. The majority of respondents were reluctant to diligently maintain medication and problem lists, indicating a continuing gap in quality of documentation. While some patterns reflect the uniqueness of BHHs, there are also similarities with other facility types. Although suboptimal, no adequate supervised housing was available following a recent inpatient admission. In 2009, Goldman et al1 found only 9 reports in the literature over the past 40 years of psychiatric M&M endeavors. His Web site, PsychEducation.org, gathers no information on visitors and produces no income for him or others. There are approximately 20,000 medical abbreviations; instead of providing an exhaustive and meaningless list, this article will focus on the most common medical abbreviations that are necessary for interpreting prescriptions and medical orders. The format on these lists will be to provide the abbreviation, followed by its intended meaning. Pearson will need a new script if she still needs this medication past August 31, 2014, regardless of how many refills were written for.
There are 5 schedules of controlled substances with various prescribing guidelines based on abuse potential, as determined by the Drug Enforcement Administration and individual state legislative branches. Medicare pays hospitals several thousand dollars more to treat septicemia than less severe hospital-acquired infections – prompting some hospitals to file what officials say are false claims. Prem Reddy, is known for buying struggling hospitals and canceling insurance contracts with managed care companies. Elaine Alquist, D-San Jose, who leads the Senate Health Committee, asked the California Department of Public Health to investigate septicemia at Prime hospitals. Another company official said the Beverly Hills home was necessary because many company executives work in Los Angeles-area hospitals but live in Apple Valley in San Bernardino County. Great for clubs, organizations, families or your own personal needs, the Contact List Template will help you get off to a quick start.
Hier1[1] University of Illinois at Chicago, United States[2] National Library of Medicine, United States1.
The introduction of such a system will provide clinicians a useful guideline through which they can replicate their decisions on similar clinical cases. Similarly, many medical records contain numerous and inconsistent medication lists, which do not reflect the actual medications taken by a specific patient. According to the results of this survey, approximately 50 percent of surveyed providers said that (1) the problem lists were not well maintained in their own clinical units, (2) approximately 55 percent said that they audit and maintain the medication and problem list on their own behalf, and (3) approximately 42 percent said that they failed to update the centralized medication and problem lists after including a problem list in each of their own progress notes.
Information presented in this article may also be of interest to behavioral health units within other types of facilities. On transfer back to the inpatient psychiatric unit, psychiatric nursing discovers he has significant hypotension, and immediately calls a rapid response. He presented to the outpatient office appearing sweaty, anxious, and admitting to alcohol relapse. While amongst health care professionals we would use the phrase sublingual as a route of administration, it may be necessary to translate 'SL' as 'under the tongue' for many patients.
In a letter to the inspector general, the lawmakers said they acted after reviewing a computer analysis of Medicare billings by the Service Employees International Union, which has repeatedly butted heads with Prime over pay and staffing issues.
Unions are outspending one of the largest employers in the State by a factor of 1300 % in just one election cycle. The template allows you to easily sort and filter by any heading, and it is ready for printing. For example, each diagnostic problem item has a unique ICD-9-CM code when each ICD-9-CM code is a diagnostic problem. Furthermore, an effective CDSS can reduce the variation of clinician’s practice plans that plagues the process of healthcare delivery. Medication lists are often obsolete (containing medications no longer prescribed) or incomplete (lacking medications that are prescribed), while multiple reconciled versions of the medication list coexist in the same medical record.
Respondents felt that the CDSS could improve problem list documentation and would benefit patient safety more than physician productivity (as shown in Fig.
PA-PSRS information is a foundation upon which facilities can identify opportunities for system improvements.
He was walked to the emergency department, where he was found to be in diabetic ketoacidosis (DKA).
The last significant item on this label is that the physician did not include their DEA number.
I would like to see what the Unions have actually done for the employee, how much of the monies do unions spend helping their members that are in foreclosures, bankruptcy, seeking higher education. It may be a valid charge but this error is so common you shouldn't let it go unchallenged. It is a one-to-one relationship between each problem and its associated ICD-9-CM code, and between each medication and its associated RxN (drug number). The embedded knowledge component in a CDSS combines patient data and generates meaningful interpretations that aid clinical decision making (Liu et al., 2006).
The dynamic environment surrounding patient diagnosis complicates its diagnostic process due to numerous variables in play; for example, individual patient circumstances, the location, time and physician’s prior experiences. Most medical records make no attempt to establish medication-to-problem relationships or ordering by indication. While the following information may provide some insight into BHH report patterns, these patterns may not reflect actual patient safety problems at a specific facility. Employers often pitch in paying for education, advancing loans in employees in tough times, providing living quarters, but we don’t see any news about unions doing something similar to their members. An effective CDSS reduces variation by reducing the impacts of these variables on the quality of patient care.3. BHHs may wish to use this information as an impetus to delve more deeply into the causative factors associated with reports in their own facility.
All we hear are union funds being swindled by bosses, funds being extravagantly spent on campaigns facilitating further expansion of the unions. The architecture of a clinical decision support systemSeveral practical factors contribute to the success of a CDSS. Staff from some BHHs have expressed difficulty identifying reportable events due to the unique aspects of their clinical setting. CV medications may be written for up to 1 year, although many states limit this to 6 months. The political involvement here is surely driven by union money to the campaigns for the upcoming elections. A phone survey by the National Patient Safety Foundation found that 42 percent of over 100 million Americans believed that they had personally experienced a medical mistake (Louis & Harris Associates, 2007). Barriers of CDSS implementationHuman knowledge and inspection is used to detect and correct errors in medical records. This article may offer them some insight into the types of events reported by facilities like theirs.Overall, BHHs submit far fewer reports to PA-PSRS than other hospitals. The minimum required technical architecture for a CDSS is identified as (1) a skilled communication engine to access disparate data, (2) a mandatory clinical vocabulary engine to perform semantic interoperability, (3) an optimized patient database to facilitate disease management, (4) a modular knowledge base to mine adequate diagnostic and therapeutic information, and (5) an effective inference engine to expedite decision making by relating embedded knowledge to ongoing problems (Pestotnik, 2005). Five common types of medical errors include (1) prescribing erroneous medications, (2) inappropriately ordering laboratory tests for the wrong patient at the wrong time, (3) filing system errors, (4) dispensing the wrong medications, and (5) failing to promptly respond to abnormal laboratory test results (Dovey et al., 2003).
After adjusting for differences in volume, PA-PSRS receives about seven reports from non-BHH hospitals for every report submitted by a BHH, Even in light of a longer average length of stay, BHHs may have lower report submission rates because their patients tend to have fewer and less serious physical conditions than patients in general acute care hospitals.
Another study indicated 225,000 deaths annually from medical errors, including 105,000 deaths due to “non-error adverse events of medications” (Starfield, 2000).
Further, they typically receive fewer and less risky interventions than patients in other types of hospitals.
Medical errors threaten the quality of health care, increased healthcare costs, and add to the medical malpractice crisis (Studdert et al., 2005). As shown in Figure 1, BHHs submit proportionately fewer reports than non-BHHs in every category of event type.
A recent study suggested that the aggressive integration of clinical evidence from health care research into diagnostic decisions could influence patient outcomes by improving clinical diagnosis, reducing unnecessary testing, and minimizing diagnostic errors.
For example, Medication Error and ADR report submission rates were approximately one-third of the non-BHH rate. The significance of accurate medication and problem listsThe need for a problem list (or diagnosis list) is clear.
There are several potential impacts to clinical practice due to these common barriers (see Table 1). While this highlights the differences in patient populations and interventions between these types of facilities, it is also worth noting that Medication Errors and Falls are significant patient safety concerns in all of these healthcare settings.    Figure 1. The problem list and medication list (list of prescribed drugs) provide an essential overview of diagnoses and treatment.
Reports to PA-PSRS by Behavioral Health   Hospitals per 100,000 Patient Days  (Jul 2004-Dec 2005)     Figure 2.
It is a very unpleasant feeling to have the SEIU constantly trying to brainwash you into believing whatever topic they have on their agenda and take your money. The problem list is a critical part of the medical record because it contains the patient’s active and resolved medical problems while the medication list contains the prescribed drugs for each diagnostic problem. Distribution of Reports to PA-PSRS   by Event Type, Behavioral Health Hospitals  (Jul 2004-Dec 2005) Examining the distribution of reports by Event Type from BHH and non-BHH facilities (see Figure 2) finds some similarities and some differences between these care settings. By the way, I don't have a Bentley or a helicopter but I could care less if someone else did. Approximately 1.16 million patient safety incidents occurred in over 40 million hospitalizations for the Medicare population yielding a three-percent incident rate.
Optimal medication and problem lists accurately reflect ordered medications and ongoing problems.
It is critical to design a useful CDSS so that it improves a clinician’s workflow, it provides satisfactory system performance, and results in acceptable system reliability.


These incidents were associated with $8.6 billion of excessive costs during 2003 through 2005. As in non-BHH facilities, Medication Errors and Patient Falls are the most prevalent types of reports.
Although the average mortality rate in Medicare patients from 2003 through 2005 was approximate 21.35 percent and overall rates have been declining, medical errors may still have contributed to 247,662 deaths.
Characteristics of individual patients are matched to a computerized knowledge base, and software algorithms in the CDSS generate patient-specific recommendations that are delivered to clinician-users of the EMR.
Patient safety incidents cost the federal Medicare program $8.8 billion and resulted in 238,337 potentially preventable deaths from 2004 through 2006. Patients in BHHs undergo considerably fewer procedures, treatments, and tests compared to patients in non-BHHs. Unions plant seeds like this in all of our heads for one purpose: to render us incapable of being happy and to keep us at odds with one another. Current state of problem list complianceSince 2006, the maintenance of the diagnosed problem list has been mandated as a patient safety feature by the Joint Commission of Accreditation Health Organization. The best available clinical knowledge is well organized, accessible to clinicians, and encapsulated in a format that facilitates effective support for the decision making process 2. BHH patients are generally more mobile and are therefore at lower risk for skin integrity problems. Approximately 211,697 patient safety events and 22,771 Medicare deaths could have been avoided with a savings of $2.0 billion from 2005 through 2007. A computerized problem list in the EMR is more readily accessible than the paper chart, and codified terms in the medication and problem lists create an opportunity to implement clinical decision support features, including knowledge retrieval, error detection, and links to clinical guidelines (Wasserman & Wang, 2003).
A useful CDSS is extensively adopted, and generates significant clinical value that contributes financial and operational benefits to its stakeholders. While BHHs have reported fewer Medication Errors and Adverse Drug Reactions per patient day than non-BHHs, these types of events constitute a greater proportion of reports from BHHs.
Nonetheless, accurate maintenance of the problem list and medication list is difficult in practice.
In addition to maintenance medications for chronic conditions, such as asthma or diabetes, psychotropic medications are associated with extrapyramidal symptoms.Medication ErrorsFifty-five percent (55%) of reports from BHHs were medication errors, compared to 25% from non-BHH facilities. A recent case report ascribed the death of a female patient to the failure to maintain her ongoing problem list by her primary care physician (Nelson, 2002).
Among both types of facilities’ medication error reports, dose omissions predominated in both.
According to another medical report, one in every 10 patients admitted to six Massachusetts community hospitals suffered serious and avoidable medication errors (Wen, 2008).
Enhanced patient safety encompasses three complementary activities: preventing errors, making errors visible, and mitigating the effects of errors. However, BHHs reported a greater proportion of extra dose, wrong drug, and wrong patient errors.Dose OmissionsTranscription errors contributed to about two-thirds of reports of dose omissions. Improvement and automation in a CDSS can assist clinicians making errors visible and augmenting error prevention.
Clinician attitudes toward and knowledge of CDSSA survey of physician attitudes showed that the perceived threat to professional autonomy was greater for CDSS than for an EMR (Walter & Lopez, 2008). A CDSS provides several modes of decision support, including alerts, reminders, advice, critiques, and suggestions for improved care. Reported missed doses were often overlooked at bedtime or when the patient was off the unit or out on a pass.
Other results indicate that the degree of clinician acceptance of a CDSS seems to be correlated with their attitudes about their professional role and their attitudes towards the computer’s role in disease management and decision-making (Toth-Pal et al., 2008).
In this way, CDSSs are able to decrease error rates by influencing physician behaviour, improving clinical therapy, and improving patient outcome (survival rate, length of patient stay, and cost). The medication process also broke down at points where orders needed to be clarified or when follow-up was indicated and did not occur. Other significant barriers to CDSS adoption have been ascribed to insufficient level of computer skills among clinicians and time constraints on clinicians. The goalTo assist physicians in maintaining the accuracy and completeness of the problem and medications lists within the EMR, the Problem List Expert (PLE) was developed at the University of Illinois Hospital (UIH) (Jao et al., 2008). This system was designed to test the hypothesis that a CDSS can assist in effectively identifying and maintaining problem-medication matches in the EMR. Assessment of physician compliance on clinical documentationSurveys and audits of medical records reveal that the diagnosed problem list and prescribed medication list are often inaccurate, out of date, or incomplete. When medication and problem list mismatches were detected by the CDSS, expert clinicians examined the EMR to identify the nature of mismatches and causes for the mismatches including missing problems, inactive or resolved problems, missing medications, or duplicate prescribing. The core of CDSS The core of the PLE is three linked database tables: the medication data dictionary, the problem data dictionary, and medication-problem relationship table. There were approximately 1,250 medication items in the UIH drug formulary added to the medication data dictionary.
There were over 15,000 problem items (derived primarily from ICD-9-CM) added to the problem data dictionary. Also, while both are dextroamphetamines, several reports indicated that Adderall was given instead of Dexedrine (and vice versa).Several wrong drug errors involved other drugs used in behavioral health with similar letter strings. The database model is constructed as a network in which medications and the problems are associated by many-to-many relationships. To simplify data query, each item in the medication data dictionary and each item in the problem data dictionary are connected by a common key attribute, an indication.
Each medication can be linked with its associated indications that can be represented as a group of relevant clinical problems. Both of these life-threatening conditions required patient transfer for intensive medical intervention. Assessment for and intervention in such ADRs may reduce risk in life-threatening circumstances.Patient FallsCompared to non-BHHs, a greater proportion of BHHs’ reports of patient falls involved falls while ambulating, in hallways, and on the grounds of the facility. BHH patients are likely to be in better physical condition and are capable of ambulating greater distances than are acute hospital patients. It is a one-to-many relationship between each indication and its related problems and medications.Each normalized medication item in the medication data dictionary can be mapped to a unique self-defined drug number. Therefore, each ordered medication can be easily mapped by computer algorithm to one or more clinical problem(s) using established medication prescribing standards. Many patients who fell while lying in bed were either asleep or were reaching for something. Methodology of decision supportThe PLE was designed to simulate both a CPOE for ordering medication and an EMR for recording medication and problem lists. One-half of the fall reports did not indicate completion of a fall risk assessment or implementation of fall precautions.
The PLE assisted clinician experts in reviewing 140 patient records in three clinical units (general internal medicine, neurology, and rehabilitation) and discovering medication-problem mismatches (instances in which a medication was prescribed but had no indication on the problem list). Of the fall reports specifying medications, 40% indicated that patients received multiple drugs prior to the fall. The matching algorithm in PLE examines each medication on the Medication List by linking its indications to the indications for those problems on the Audited Problem List through the defined association in the Medication-Problem Relationship Table of the PLE.
A machine-learning algorithm is employed to correctly distinguish and classify the medications and problems entered in the CPOE.
For example, injuries during recreational activities are frequently reported, as are instances of aggressive behavior in behavioral health patients either towards one’s self or other patients, and possession of contraband. A data-mining algorithm is employed to discover the pattern and the relationship between the prescribed medications and the ongoing problems in the EMR. Some reports also indicate cases in which a change in physical condition requires transfer to acute care.ConclusionPA-PSRS provides a wealth of information for behavioral health hospitals.
The data-mining algorithm facilitates the medication-problem matching and database management within a large set of data. PA-PSRS is a springboard from which these facilities can monitor their own data to identify unique patterns and contributing factors. Several common types of medication list errors (for example, unnecessary medications, inadvertently added medications, and missing medications) and problem list errors (for example, failure to remove inactive or resolved problems and failure to add active problems) may risk patient safety and can be fixed by physicians during chart audits.Other key components of the PLE are a patient data repository and a user interface.
From this information, they can then develop corrective actions, measure outcomes, and ultimately improve patient safety. Through the enhanced user interface, physicians are able to create new patient records, create problem lists, and order medications. When a new medication is ordered through the CPOE, the PLE assists in checking if an appropriate problem is on the active problem list that is an indication for the medication ordered. 4 shows the infrastructure and workflow of the PLE implementation, where the problem list obtained from UIH’s EMR is termed the Reported Problem List; the medication list obtained from UIH’s EMR is termed the Medication List, the list for medication-problem relationships based upon clinician expert review is termed the Audited Problem List. The order of data entry was the patient’s Reported Problem List, Audited Problem List, and Medication List, which were saved in the Patient Data Repository without patient identities.
The PLE first examined the existence of entered items in the Medication Data Dictionary and the Problem Data Dictionary. Results The PLE automates the maintenance of the medication and problem lists and detects likely medication-problem mismatches as visible medication and diagnostic errors on the screen of the EMR. With regard to the problem list, The PLE found that approximately 11% of patient records had no problems listed on the Reported Problem List.
The remaining 78% of patient records showed various levels of problem deficiency on the Reported Problem Lists (i.e. Most of these common medications are related to nursing diagnoses that are commonly not added to the problem list by physicians (e.g. The improvement rate of medication-problem matches on the problem lists was equal to the variance of the percentages of matched medications on the Medication List in the individual inpatient unit before and after expert chart review.One approach to improve poor physician compliance with maintenance of the problem list is to link the ordering of medications to the problem lists by using a CDSS to automate the process of maintaining the EMR. In other words, when a medication is either ordered by CPOE or ePrescribing, the CDSS automates the process of adding the appropriate problem (the indication for the medication) to the problem list. The PLE, an innovative CDSS, automates the maintenance of both medication and problem lists in the EMR. It exploits advanced decision support strategies to yield higher patient safety by improving the accuracy of the medication and problem lists. It effectively identifies potential medical errors to some degree and improves problem list documentation in the EMR.5.
Future challengesThe potential to develop more sophisticated computerized alerts and other types of CDSS will grow as more clinical data becomes accessible electronically. Automated computerized-based applications utilize the accurate and structured clinical information available in the EMR to improve patient care and lower costs. Preliminary studies have shown that the CDSS is an essential cornerstone of efforts to reduce medical errors and improve patient safety.
This e-Ordering system will be supported by a CDSS that will guide clinicians to order the most appropriate diagnostic tests. The e-Ordering system will electronically document the appropriateness of each order and provide value-assurance to the patient and measurable, comparable data to the payer (insurer).6. ConclusionThe preponderance of evidence indicates that CDSSs are effective to some degree in the preventing medical errors and in improving patient safety, especially when embedded within an EMR and directly intercalated into the care process. Although the results of support CDSSs have been far less positive when applied to the problem of improving clinical diagnosis, or improving ongoing care of patients with chronic diseases, advances can be expected in the future.An effective CDSS can assist users of an EMR to significantly reduce medical errors and thus making healthcare more efficient and promoting the quality of health care. Despite the federal government's recent unveiling of grants and incentives for the adoption of HIT, health care providers still face numerous challenges in transitioning to the full adoption of EMR systems (Hart, 2009).



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