Agnes Gibbons was admitted through the hospital’s emergency department with congestive heart failure. During her admission she was asked to verbally acknowledge whether her demographic data were correct. Ms. Gibbons did so. Extensive diagnostic tests were done, including radiology studies. It was later discovered that all of Ms. Gibbon’s information had been entered into another client’s file. How would you correct this situation? What departments, or other agencies, would need to be informed of this situation?
A data entry flaw occur in the case of Agnes Gibbons. According to Hebda ; Czar (2012) electronic medical records (EMRs) should be equipped with mechanisms that allow for a systems checks that are meant to prevent gross data entry errors such as the case being discussed here. Safeguards such as data cleansing technology, mandatory queries such as questioning patients about allergies each time an entry is made, flagging users about potential duplicate entries, and printout prompts assist with improving the integrity of information documentation.
Data verification techniques should be used and said verification techniques include confirming with the client verbally as the nurse did here, having the client physically do a self-review of the data on the screen, and asking the client to review a printed version prior to finalizing the entry. Being that the data entry occurred even while the nurse use minimal safeguards, the appropriate action to take is to scrub or cleanse the data. However, it is still important to note that the error occurred in the first place.
Then, the appropriate data should then be entered into the correct patients chart. Finally, every department that interfaces with the medical record should be notified if not equipped to happen automatically through IS/IT. This dissemination of information includes departments such as (and not limited to), admitting, business/finance office, lab, diagnostic imaging, ER, medical records, transcription, the primary care provider or any consults and possibly the insurance provider.