Development of an Interdisciplinary Critical Care Problem List

Critical Care, 2009

Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research. CLABSI = central line-associated bloodstream infection; CPOE = computerized provider order entry; HCAP = health care-associated pneumonia; ICU = intensive care unit; OR = operating room; VAP = ventilator-associated pneumonia.

Journal of Critical Care, 2010

The aim of this study was to describe the new advancements in Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) terminology and its applicability to critical care documentation. Narrative review of existing literature published in indexed medical and health informatics journals and of gray literature available on the Internet and personal communication with authors and researchers engaged in SNOMED-CT projects related to critical care are conducted. Systematized Nomenclature of Medicine-Clinical Terms is a system of comprehensive health and clinical terminology that covers most of the needs of health care documentation. It will potentially become the terminology of clinical enterprise and administrative information systems. Despite a ground swell of international support from health information management experts, the terminology remains unknown to most clinicians. We discuss the reasons why clinical familiarity with SNOMED-CT is an important prerequisite to proceeding with local or national electronic health records or clinical information systems. We propose that SNOMED-CT is suitable for use in critical care; however, work is urgently required to validate the completeness of terminology and to determine clinicians' perceptions on the utility of such a standardized terminology for use in critical care clinical information systems.

Proceedings / AMIA ... Annual Symposium. AMIA Symposium, 2002

SNOMED Clinical Terms is a comprehensive concept-based health care terminology that was created by merging SNOMED RT and Clinical Terms Version 3. Following the mapping of concepts and descriptions into a merged database, the terminology was further refined by adding new content, modeling the relationships of individual concepts, and reviewing the hierarchical structure. A quality control process was performed to ensure integrity of the data. Additional features such as subsets, qualifiers, and mappings to other coding systems were added or updated to facilitate usability. We then analyzed the content of the completed work. This paper describes the refinement processes and compares the actual content of SNOMED CT with the early data obtained from analysis of the description mapping process. As predicted, the majority of concepts in SNOMED CT originated from SNOMED RT or CTV3, but not both.

Journal of Veterinary Diagnostic Investigation, 2017

Much effort has been invested in standardizing medical terminology for representation of medical knowledge, storage in electronic medical records, retrieval, reuse for evidence-based decision making, and for efficient messaging between users. We only focus on those efforts related to the representation of clinical medical knowledge required for capturing diagnoses and findings from a wide range of general to specialty clinical perspectives (e.g., internists to pathologists). Standardized medical terminology and the usage of structured reporting have been shown to improve the usage of medical information in secondary activities, such as research, public health, and case studies. The impact of standardization and structured reporting is not limited to secondary activities; standardization has been shown to have a direct impact on patient healthcare.

British Medical …, 2000

Jama-journal of The American Medical Association, 1995

2004

Quality and Safety in Health Care, 2001

Delivering safe health care: safety is a patient's right and the obligation of all health professionals* One fundamental guarantee that we cannot give our patients is that faults and errors in the healthcare system won't harm them. Of course, health care is by its nature risky. Not everyone undergoing surgery for an aortic aneurysm survives. Many interventions carry risks. But these risks are mostly small and usually quantifiable. Ideally, patients understand the possible risks and benefits before choosing to undergo a procedure. For some patients these are diYcult decisions. Although healthcare professionals may discuss risks of treatment, they do not speak about risks of harm from the system-or even about such harm when it occurs. Recent studies in the United States, Australia, and the United Kingdom and reports from the US Institute of Medicine and the UK Department of Health have drawn attention to the chronic "unsafeness" of health systems worldwide. 1-7 This attention is not new. What is new is that preventable, iatrogenic injuries are being quantified and openly discussed. For example, adverse drug reactions have become a national issue in the United States-studies show that adverse drug events occurred in 6.5% of hospitalisations. 8 These reports have highlighted the tensions between accountability and improvement, the needs of individual patients and benefit to society, and production goals and safety. Most causes-and solutions-lie in the systems of care and how we work. Healthcare professionals, however, focus energy on individual patients, tackling diYculties in the system as they appear-often as separate problems and not in parallel. Individual care is, of course, crucial but, unless attention is given to the system, our patients are at risk from a faulty service. For example, inadequate handovers can mean that vital information is lost between diVerent care givers and services. Is it that the word "system" is anathema to many healthcare professionals? Just getting health professionals to work harder or exhorting them to be safer will not help; the system of care must be redesigned. We must instil a chronic sense of unease-a constant awareness of risk in every action. 9 Such attention to risk enables crews of aircraft carriers to launch and land several planes every day on decks the size of two football fields with *This is a version of an editorial which appeared in the BMJ 2001; 323:585-6.

Proceedings a Conference of the American Medical Informatics Association Amia Annual Fall Symposium Amia Fall Symposium, 1997

Mayo Foundation is developing synonym rich entry points for the recording of patient problems by clinicians, which will map to the KP-Mayo Convergent Medical Terminology. We describe the empirical sources for these terminology components, and how the number and complexity of the terms could be substantially reduced by the introduction of a Qualifier axis. The expressive power of these entry points is dramatically enhanced by this axis. This work is being integrated into terminology navigation modules being jointly developed with Lexical Technology, which leverages UMLS content. It will from the basis for structured problem entry into Mayo's Computer-based Electronic Record.

AORN Journal, 2013

No sponsorship or commercial support was received for this article. Disclaimer AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Center approves or endorses products mentioned in the activity.

El presente trabajo es un compendio de fichas terminológicas del campo de ciencias de la salud con enfoque en medicina general, realizado por la alumna Diana León Contreras como trabajo final de la materia Métodos de Investigación Terminológica impartida en la Facultad de Idiomas de la Universidad autónoma de Baja California por la maestra Vicki Lynn Villezcas durante el ciclo escolar 2015-1. Este documento consta de 100 términos médicos con su equivalencia en español- inglés, así como de 20 fichas especializadas, dando un total de 120 fichas ordenadas alfabéticamente. Para la realización de este trabajo se contó con la asesoría de la Dra. María Esther Cuellar, quien proporcionó materiales de consulta y apoyo a lo largo del proceso. Este compendio terminológico servirá como material de referencia para facilitar el trabajo del traductor-intérprete en su desempeño profesion

Springer eBooks, 2017

part of the material is concerned, specifi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specifi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Journal of the American Medical Informatics Association

Health care in the United States has become an information-intensive industry, yet electronic health records represent patient data inconsistently for lack of clinical data standards. Classifications that have achieved common acceptance, such as the ICD-9-CM or ICD, aggregate heterogeneous patients into broad categories, which preclude their practical use in decision support, development of refined guidelines, or detailed comparison of patient outcomes or benchmarks. This document proposes a framework for the integration and maturation of clinical terminologies that would have practical applications in patient care, process management, outcome analysis, and decision support. Arising from the two working groups within the standards community--the ANSI (American National Standards Institute) Healthcare Informatics Standards Board Working Group and the Computer-based Patient Records Institute Working Group on Codes and Structures--it outlines policies regarding 1) functional characteri...

Journal of the American Medical Informatics Association, 1994

To analyze the terms used by nurses in a variety of data sources and to test the feasibility of using SNOMED III to represent nursing terms. Prospective research design with manual matching of terms to the SNOMED III vocabulary. The terms used by nurses to describe patient problems during 485 episodes of care for 201 patients hospitalized for Pneumocystis carinii pneumonia were identified. Problems from four data sources (nurse interview, intershift report, nursing care plan, and nurse progress note/flowsheet) were classified based on the substantive area of the problem and on the terminology used to describe the problem. A test subset of the 25 most frequently used terms from the two written data sources (nursing care plan and nurse progress note/flowsheet) were manually matched to SNOMED III terms to test the feasibility of using that existing vocabulary to represent nursing terms. Nurses most frequently described patient problems as signs/symptoms in the verbal nurse interview and intershift report. In the written data sources, problems were recorded as North American Nursing Diagnosis Association (NANDA) terms and signs/symptoms with similar frequencies. Of the nursing terms in the test subset, 69% were represented using one or more SNOMED III terms.