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New AORN RPs provide guidance on medication, documentation

Publish Date: 3/26/2012

The development of AORN recommended practices (RPs) is like a journey—creating these documents is “a long and bumpy ride, but we’re having fun with it,” said Antonia Hughes, MA, BSN, RN, CNOR, chair of the AORN Recommended Practices Advisory Board. Hughes described the RP development process, urging attendees to participate during the public comment process.

Bonnie Denholm, MS, BSN, RN, CNOR, described the path that she and her coauthors took to develop the “Recommended practices for medication safety.” The document provides guidance to perioperative nurses to help them implement, evaluate and develop safe medication practices. The document stresses the importance of creating a multidisciplinary team, pharmacists in particular, to develop medication safety plans. Other topics in the document are drug diversion, safe disposal, preoperative and postoperative considerations, hazardous medications and new technologies. Avoiding disruptions during medication processes is important to prevent patient care errors.

“Reporting is key for this document,” Denholm added, because the evidence is clear that the more nurses report near misses, the easier it is to identify trends. AORN recommends that facilities participate in voluntary national reporting programs to assist in these efforts. 

When nurses document and report information regarding delivery of care, treatments and services provided, this captures data that describe how nurses support positive patient outcomes, according to Janice Kelly, MS, RN-BC, business leader, SYNTEGRITY, who presented on the “Recommended practices for perioperative health care information management.” Health care documentation also serves as evidence in legal matters and promotes continuity of patient care.

One key to ensuring consistent, useful and high-quality documentation is to involve multidisciplinary team members. Documentation should meet regulatory compliance (both federal and state), use structured vocabulary, be in sync with the nursing workflow, and maintain security and confidentiality.

“If you haven’t gone electronic yet, you will,” Kelly predicted. The move to electronic documentation is not a destination, it’s a journey, she added, because there will always be optimizations and revisions, and nursing practice is constantly changing.
 

 

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