Discussion Apply Knowledge

Quality and Safety Issue Observed

One significant quality and safety issue observed in the video was the lack of comprehensive and accurate medical record-keeping. The case of Pat revealed significant suboptimal aspects of recording and transferring her medical history and the specifics of her treatment courses between the involved care teams. In addition to that, she had to endure excruciating pain, particularly tenderness in her right breast, which was constantly dismissed as normal even after the surgery. When she finally fell gravely ill, and the ER nurse was charting her recent admission for implant surgery only four months previous in the same hospital, the woman was listed as not having such surgery (Patient Safety Movement, 2020). It was quite revealing as it expressly revealed a lack of proper adherence in database updating and retrieving core patient data. The impact of this issue was profound: The infection associated with the implant remains undiagnosed and untreated, which led to the deterioration of Pat's condition. This delay indicates that she received an inadequate timely diagnosis and treatment, which later led to her suffering, more readmissions to the ICU, and, unfortunately, her death.

Role of Technology in Quality and Safety

Technology has contributed to the problem and may be part of the solution for the quality and safety issues discovered in Pat's case. On the one hand, the technology that was applied to maintain and provide access to the records of patients was not properly developed. The lack of documentation of the implant surgical procedure clearly and conspicuously to all the related health care practitioners meant a glaring hole in Pat's care. However, proper and timely treatment was difficult due to the lack of integration and compatibility between the different healthcare information systems. On the other hand, the technology could have gone a long way in enhancing the situation if applied properly. Comprehensive electronic health records should also be able to store all the patient information concerning the patient and make it easily accessible to all the healthcare providers who are likely to handle or treat the patient at one point or another (Tapuria et al., 2021). Also, sophisticated alerting may have raised concerns over episodic inflammation that Pat felt long after surgery as a complication that might have been averted.

Policy Recommendation for Information and Communication

An effective information and communication technology policy should be implemented to avoid the quality and safety problems raised in Pat's instance. One of these policies could require all healthcare facilities to use interoperable electronic health record (EHR) systems. This policy would state that all patient records must be kept in an electronic format that can be efficiently searched and accessed by any healthcare provider that needs to see the patient's records. Also, the policy should ensure that there is integration of clinical decision support systems, CDSS within the EHRs that are linked. These systems allow for secondary notifications to healthcare providers about certain matters like postoperative complications based on the recorded symptomatology or the patient's health history (Olakotan & Mohd Yusof, 2021). Moreover, proper auditing and quality assurance should ensure that all non-electronic and electronic medical communication, including telephone consultations, have been properly recorded in the patient's record. Promoting detailed and documented accounts of all aspects of care and communication between patients and health workers can further improve the patient care processes and increase patient safety and satisfaction, along with better outcomes.

In conclusion, Pat's story highlights the importance of appropriate medical documentation and the proper adoption of technology solutions. These gaps in proper documentation translated to delays in diagnosis and treatment, issues that need to be fixed through policies supporting the meaningful use of electronic health records, and clinical decision support. Increasing awareness and communication within the treatment teams can reduce risks, promote better patient care, and make future mistakes like those made in Pat's case unnecessary.