Nursing diagnosis the ehr has the cds built in to

●
NURSING DIAGNOSIS - THE EHR HAS THE CDS BUILT IN TO ALLOW FOR GUIDANCE AND
DEVELOPMENT OF A PROPER NURSING DIAGNOSIS AND PROMPTS TO BUILD A CARE PLAN.
●
PLANNING - THE BUILD OF THE EHR ALLOWS FOR THE NURSE TO GO TO THE NARRATOR
AND EVALUATE ALL ORDERS AND DOCUMENTATION FROM ANCILLARY SUPPORT TEAM
MEMBERS TO CONTINUE WITH THE PLAN OF CARE.
● IMPLEMENTATION - THIS IS THE ROLE OF CDS TO GUIDE THE PROVIDER IN THE HIGHEST
QUALITY DIRECTION FOLLOWING THE PATH OF EVIDENCED BASED PRACTICE.
●
EVALUATION - THE ABILITY TO REVIEW THE EHR AND CONDUCT AUDITS AND OR ROOT
CAUSE ANALYSIS IF THERE ARE ANY CONCERNS.

D.2. CULTURE OF SAFETY
HOW DOES A HEALTH INFORMATION SYSTEM SUPPORT A CULTURE OF SAFETY?
●
IDENTIFICATION OF PATIENT SAFETY RISKS
○
IMPLEMENTATION OF SAFE TECHNOLOGY INTEGRATION
■
CARDIAC MONITORS
■ VENTILATORS
■ INFUSION PUMPS
○
UTILIZATION OF COMPUTERIZED PHYSICIAN ORDER ENTRY (CPOE)
●
ENCOURAGEMENT AND FOCUS ON ALL INDIVIDUALS REPORTING EVENTS FOR REVIEW AND
ASSESSMENT TO PROMOTE INCREASED QUALITY OF CARE
● PRO-ACTIVE REVIEW OF ANY NEAR MISSES OR ADVERSE EVENTS REPORTED WITH KEY
PLAYERS INVOLVED IN REAL TIME
○ TIMELINE
○
KEY ISSUES
○
CONCERNS OF PROCESS
○ EQUIPMENT/TOOLS

D.3. HUMAN FACTORS
HOW DO HUMAN FACTORS LEAD TO ERRORS, NEAR MISSES, AND ADVERSE
EVENTS?
●
HARM TO PATIENTS CAN EXIST FROM FATIGUE
●
SHORT-STAFFING
●
DISTRACTION
●
LACK OF KNOWLEDGE
● BROKEN PROCESSES AND WORKAROUNDS
● DISREGARD FOR POLICY AND PROCEDURES
● RELIANCE ON TECHNOLOGY
●
USABILITY
(JONES & BARTLETT LEARNING, 2014, P. 41)

D.4. CLINICAL DECISION SUPPORT