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Welcome to Pearls from Peer Review series

28 Feb 2021

Regular insights for problem solving, preventing harm

By: Matt Boles, MD, VPMA and Jenny Williams, MD, Chair, Multidisciplinary Peer Review Committee Chair

Peer Review provides a safe and protected venue to discuss clinical outcomes among peers, as many of you know. These discussions often involve problem solving and system fixes that protect our patients, staff, and providers from future harms.

We’re both honored to introduce this new series — to share “Pearls from Peer Review,” so our medical staff can learn and adapt their practice patterns when appropriate. Starting now, this will be a recurring article in Common Ground. Our goal is to benefit all medical staff.

Enjoy, and let us know what you think:

  • Periodically review order sets:

    Many order sets are lengthy with multiple medications included. While these order sets are convenient, highly recommended, and preferred for routine use, please be aware of all the items and particularly the medications included in your order sets. There may be medications buried within your order set to which your patient is allergic, or wishes to avoid, requires CDI justification, or you’ve just forgotten about. Take a moment every so often to review your order sets to make sure you know what you’re ordering and are ordering what you intend for the patient to receive.
  • Remember to use Medical Interpreter Services for your patients:

     According to federal statutes and regulations and hospital policy, we are required to offer a certified medical interpreter to all patients with limited English proficiency (LEP) or language disability (or has an impairment like hearing loss, who may need ASL). It is not acceptable to use a patient’s family members to interpret for them. If you are fluent in another language besides English, you must take a test to certify as a medical interpreter for that language in order to speak to patients in that language about their medical condition. Even if a patient declines an interpreter, please note that you as the provider have a right to have an interpreter present and are strongly encouraged to use one for your own protection. Please document that an interpreter was present when communicating with LEP or language disability patients. Also, there are many ways to use interpreter services, including in person, by phone, or with a video assist device. Please ask the patient’s nurse or the unit’s charge RN if you need help with interpreter services.
  • Respond to data from imaging reports that auto-populate your notes:

    Please carefully review all data, including imaging reports, which auto-populate your chart notes. For example, be sure to address incidental findings noted in imaging reports, and consider arranging for future outpatient follow up, if necessary. Once you sign the note, you are responsible for all information contained within it, including the imaging report.