Medication management is crucial for patient safety and quality care. QSEN competencies guide nurses in key areas like patient-centered care and evidence-based practice. The Joint Commission's abbreviation guidelines help prevent errors by standardizing medical terminology.

Technology plays a vital role in drug administration safety. Electronic health records, barcode systems, and smart infusion pumps reduce errors and improve patient outcomes. Health informatics integrates these technologies, enhancing care coordination and data security across healthcare settings.

Documentation and Informatics in Pharmacology for Nurses

QSEN competencies for medication management

• QSEN competencies aim to improve patient safety and healthcare quality by focusing on:
  • Patient-centered care involves prioritizing patient preferences and needs in medication management (shared decision-making)
  • Teamwork and collaboration among healthcare professionals enhances communication and coordination in medication processes (interdisciplinary rounds)
  • Evidence-based practice guides medication-related decisions using the best available research and clinical expertise (clinical practice guidelines)
  • Quality improvement initiatives continuously monitor and optimize medication processes to reduce errors and improve outcomes (medication error reporting systems)
  • Safety emphasizes the prevention of medication errors through strategies like medication reconciliation and double-checking high-risk medications (insulin)
  • Informatics leverages technology to support medication safety, such as electronic health records and barcode scanning systems (CPOE)

Joint Commission's abbreviation guidelines

• The Joint Commission's "Do Not Use" abbreviation list reduces medication errors caused by ambiguous or confusing abbreviations
• Examples of "Do Not Use" abbreviations:
  • "U" or "u" should be replaced with "unit" to avoid confusion with other abbreviations or numbers
  • "IU" should be written as "international unit" to prevent misinterpretation
  • "Q.D.," "QD," "q.d.," or "qd" should be written as "daily" to avoid confusion with other abbreviations like "QID" (four times daily)
  • "Q.O.D.," "QOD," "q.o.d.," or "qod" should be written as "every other day" for clarity
  • Trailing zeros after decimal points should be avoided (write 1 mg instead of 1.0 mg) to prevent tenfold dosing errors
  • Leading zeros before decimal points should be used (write 0.5 mg instead of .5 mg) to avoid misinterpretation
  • "MS," "MSO4," or "MgSO4" should be written as "morphine sulfate" or "magnesium sulfate" to prevent mix-ups

Technology in drug administration safety

• Electronic health records (EHRs) provide a centralized, comprehensive patient record that enables real-time access to medication history and facilitates communication among healthcare providers
• Computerized provider order entry (CPOE) systems allow electronic prescribing, integrate with drug databases to check for interactions and dosing errors, and reduce errors associated with illegible handwriting (transcription errors)
• Barcode medication administration (BCMA) systems ensure the "five rights" of medication administration by scanning patient wristbands and medication barcodes to verify accuracy and alert nurses to potential errors (wrong patient)
• Smart infusion pumps incorporate drug libraries with preset dosing limits and alerts to prevent programming errors and overdoses while providing real-time data on medication administration (continuous infusions)
• Clinical decision support systems (CDSS) offer evidence-based recommendations and alerts based on patient data to assist in drug selection, dosing, and monitoring, helping prevent adverse drug events (renal dose adjustments)

Health Informatics and Data Management

• Health informatics integrates healthcare information technology systems to improve patient care and outcomes
• Interoperability enables different healthcare information technology systems to exchange and use data seamlessly, enhancing coordination of care across various settings
• Data security measures protect sensitive patient information from unauthorized access or breaches, ensuring confidentiality and compliance with regulations
• Medication reconciliation processes use health informatics tools to compare a patient's medication orders to all medications they have been taking, reducing medication errors during transitions of care
• Nursing informatics applies information technology to nursing practice, education, and administration, supporting evidence-based practice and improving patient care quality