Inaccurate data captured during an encounter with a health care provider can result in harm to a patient in several ways. Serious problems can occur when a health care provider receives and/or hears incorrect information regarding the medications a patient is taking. Some patients have problems pronouncing difficult medication names; and when this occurs, the provider may erroneously hear a name that may be similar to the patient’s medication. Since severe interactions can occur between medications, a provider can, for example, prescribe pills that would not negatively interact with the name that was heard but would with the correct name.
If possible, obtain the patient’s prescription record or actual medications. To minimize medication errors due to incorrect patient input, repeat what you heard the patient say, which should result in confirmation of your details or a correction of them by the patient. Such a precaution should be taken with all patient data. Health care providers can also minimize risks of obtaining incorrect information by avoiding ‘medicalese’and not speaking at a university level English. If a family member has to translate for the patient, incomplete information may be given because the patient may not want the details known to family members. Also, if possible, speak with the patient alone. (Nurse Susan, 2009)
The accuracy and completeness of a patient’s data received by a healthcare provider is due to many things. Often not remembering well presents a problem, especially in older people.
A relaxed and comfortable setting can be of help, as can a mixture of open-ended and close-ended questions. Yes or no questions can sometimes be difficult to answer because it may be difficult for them to be that precise. This is where a good health care provider asks an open-ended question in a non-judgemental manner. (Guide to Taking a Patient History)
Guide to Taking a Patient History. Retrieved on February 20, 2013, from http://www.english-lss.com/english.
Nurse Susan. (2009). Just Answer.Health. How might inaccurate data captured during the patient encounter. Retrieved on February 13, 2013, from http://www.justanswer.com/ health.