Language matters: Contraindications and indications A contraindication is a specific situation in which a drug, procedure, or surgery should not be used, because it may be harmful to the patient. Some treatments may even cause unwanted or dangerous reactions in people with allergies, high blood pressure, or pregnancy. Indication is a term describing a valid reason to use a certain test, medication, procedure, or surgery. Indications for medications are strictly regulated by the Food and Drug Administration. They routinely include them in the package insert under the phrase “Indications and Usage.” What do the terms contraindication and indication have to do with the prevention of medical errors? Contraindication on a medication for a particular patient is a red flag signaling that a pharmacological combination will not work in this instance. On the other hand, an indication allows that the medication is appropriate for the patient. Professional judgments The therapist is the medical professional who the patient looks to as having sufficient expertise to make a decision that will not only do good but will do no harm. This trust should not be taken for granted. If it is, it puts the medical professional in a high-risk category of having a medical error on his or her record. Professional judgment will not only be made not only with training and information gathering but also with wisdom, knowledge of ethics and professional integrity. A therapist who maintains a high level of ethics and integrity will go the extra mile to ensure that his or her professional judgments are accurate and carefully thought out. Patient’s best interest One of the best safeguards for a medical professional against medical errors is to communicate information to the patient. Properly conveying this information will give the patient a sense of security that the medical professional has
his or her best interest at heart and is truly concerned about the patient’s well-being. If the therapist is not inclined to explain a diagnosis, a plan of treatment, or the ongoing results of the treatment, the patient may feel that they are trying to hide something. The patient needs to know the reason that a medication was suspended or a certain treatment plan was adjusted. The patient will appreciate knowing that his or her therapist read a contraindication or an indication and took heed. Maintaining an open dialogue between the therapist and patient is key. Professional training National and state regulatory agencies for certain industries mandate continuing education or professional development units on a periodic basis. For the healthcare professional, that requirement should be the baseline for training. Every case that the therapist receives into his or her care has variables all its own. The question to be asked here is this: If you did an intake on a new patient with a condition you were not familiar with, did you go the extra mile to research all avenues of treatment? A therapist may perform a subjective history and collect the objective data, but other questions might present themselves regarding the best course of treatment. What would you do? Hopefully your answer is, “I’d hit the books!” Professional examination, evaluation, diagnosis Professionalism must always be at the top of the list when dealing in the medical field. From the initial evaluation, the therapist must show integrity and care in preparing a diagnosis or treatment plan. The therapist must also be able to convey this plan to the patient in a way that the patient can fully understand the course of action. This requires the therapist to utilize their knowledge and expertise to make a professional determination for a treatment plan that will be successful and beneficial.
MEDICAL DOCUMENTATION AND COMMUNICATION
professional commences to focus on these transition points, they will see revealing discrepancies. Verify existing documentation The absolute importance of documentation cannot be stressed enough. Weariness or laziness must never supersede professional responsibility to a patient. If a therapist is looking at documentation and it just seems like there is something that is missing, they can go back to the referring physician and pose the question to him or her. There is never a reason to rush to judgment if all existing documentation is not understood and/or verified. Document after dosage administration/treatment Once again, documentation is the name of the game. Recording procedures and documenting actions is less than exciting and can quickly become boring. Nonetheless, it is a crucial part of treating a patient accurately and effectively. It is the only way to precisely evaluate how the therapy routine is advancing. Documentation also provides a written record of the patient’s progress as well as their strengths and weaknesses. Documentation allows the therapist to change the therapy, consult anew with the referring doctor, or reevaluate the progress. Computerized ADE monitoring A computerized adverse drug event (ADE) monitor uses electronic medical records. Humans can use smart monitors such as automatic paging and computerized ADE monitoring to track many more parameters than would otherwise be possible. This would be most beneficial first
Communication failures are the leading cause of serious medical errors in healthcare settings. Improved communication may play a major role in reducing the risk of litigation. The primary question is not whether to disclose an error but how to disclose an error in the most productive and ethical fashion. A study on patient/doctor communication identified specific skills that the medical profession can utilize to reduce malpractice claims. Communication at transition points The delivery of care often involves moving the locus of care among sites and providers. Many times these handoffs are fraught with errors. One strategy for reducing errors during these transitions is to reconcile medication orders between transition points (such as care settings of hospitals and outpatient facilities) as well as between points within one particular organization (intensive care unit and the general care unit). A typical reconciliation could involve the comparison of what a patient is taking in the first setting to what is being administered in the next setting. This will assist in avoiding errors of transcription, omission, duplication of therapy, and drug/drug or drug/disease interactions. When the medical Solutions for patient safety improvement Research into medical errors attempts to not only identify the causes and extent of errors but to develop and test better ways to prevent errors by reducing the reliance on human memory. Translating knowledge into practical solutions should be the ultimate goal in the world of computerized research documentation and implementation.
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