Eliminating Errors of Omitted Care
Our Researcher: Ronald J. Piscotty, Jr., PhD, RN-BC, FAMIA
By Dan Mezibov
Health care errors are the third leading cause of death in the United States after cancer and heart disease, accounting for nearly 440,000 deaths and costing the nation an estimated $17 billion annually. While errors of commission (doing the wrong thing) have received much attention, errors of omission (delaying or not providing needed care) are believed to occur more frequently.
Providers must wade through multiple sections of a patient’s lengthy electronic health record to find the information they need to make a clinical decision, often wasting critical time and expense. “Right now, it’s a haphazard system,” explains Ronald Piscotty Jr., PhD, RN-BC, UMSON assistant professor and a former clinical information systems analyst. “I’m trying to develop something more efficient, focused, and intelligent.”
In a feasibility study funded by a Dean’s Research Scholar Award, Piscotty is developing a prototype clinical dashboard to display instances of omitted nursing care visually. He is working with five high-volume hospital units to mine patients’ electronic health records to find instances when required treatments and procedures were not documented. In the study’s first phase, slated for completion this fall, Piscotty is using special software to display necessary care to protect a patient from infections from catheter and intravenous insertion sites, any necessary care that might have been missed, and an analysis of trends during a patient’s care.
A second phase will determine the dashboard’s success in reducing care omissions. Piscotty hopes to extend the dashboard’s use to prevent other conditions, such as falls, pressure ulcers, and ventilator-associated pneumonia, as well as to manage chronic diseases.