Nursing data quality is very important because healthcare providers are making decisions based upon the data. The data integrity is important in healthcare because treatment decisions are based upon the data in the charts. Recently someone at work put in the wrong intake and output for a patient and the physician treated the patient as if he was fluid overloaded and in actuality he wasn't. I went back to our paper flowsheet and found the correct entries and put it into the computer charting system accurately. It is important to remember that one wrong keystroke can cause the patient's plan of care to be harmful or wrong and it can also be inaccurate reflection of the patient's status. Accurate and quality data are important in healthcare to diminish mistakes and harm to our patients. In our Hebda book, it states that "data provides the building blocks in the formation of knowledge". This is so true because it is all we have to rely on when treating patients. In order to ensure correct data entry and collection, staff must be educated and proficient in the use of data collection systems. They must also have the knowledge that it is important to accurately reflect the patient's status because if the dat isn't correct, patients may be harmed.
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I agree with your comments about data quality being important because treatment decisions are based upon the data. If you think about it, nursing is integral in the matter of data collection as they are with the patient 24/7 in the hospital. The doctors round in the morning and may call in for updates, but they are relying upon our overall data for the 24 hour period, so it is important to get it right. Your stated example is just one example of many that occur everyday in hospitals across America. I know the information that has been released in the media about medical treatment errors are staggering, I wonder how many begin with charting or data errors. I know there is a balance between entering too many comments in charting and not enough; it seems there is a movement (at least in my perception) to minimize the free text in charting. I realize the free text is difficult to data mine, but it can provide valuable rationale and status reports for our care.
ReplyDeleteI don't want to sound cavalier by saying that as long as humans are involved there will be errors, but I believe it is true. We can be valiant and conscientious about our nursing practice and data entry, but in the end, we are human and therefore I believe, prone to error.
Kim