Nonetheless, nurses, no matter how logical they might think and act, are simply human beings who are capable of committing certain errors every once in a while. In the local scene, our nurses seem to be more exposed than ever to certain mistakes due to extended hours of shift, heavier workloads, and replacement of experienced nurses by newly-trained and inexperienced young ones. With this in mind, Filipino nurses, especially the newbies, should always remember to always avoid miscalculations and mistakes.
Sometimes nurses sign-off on medications that were given to, but not necessarily taken by, patients. This is not a mistake and may not be an error, but the nurse’s documentation could be incorrect.
Also, nursing environments are intense, and a patient may not receive his or her medications at all. And, in some organizations, if medications are late or missed, the nurse may be disciplined. Such policies may lead to nurses signing off on missed medications and disposing of them to avoid the discipline.
Other problems involve “early” documentation—indicating on a chart that you’ve done something before you actually do it. You may fully intend to do it but time, events, or both intervene—and the chart is falsified.
Attorneys and expert witnesses review documentation to evaluate how the standard of care was fulfilled. They may ask:
• Did the nurse collect the appropriate assessment data?
• Did he or she identify the problem?
• Did he or she come up with a plan?
• Did he or she carry out the plan?
• Did he or she update the plan when the person’s condition changed?
These are the flaws in documentation that most often influence findings of liability and confuse the understanding of what happened to a patient.
1. The nurse did not time and date the record. The entries are not signed.
2. The nurse copied and pasted someone else’s electronic documentation including that person’s initials and details of a previous shift’s events. This is becoming an increasing critical issue.
3. The nurse created a late entry without labeling it as such. The nurse hoped no one would recognize the information was added in after the fact.
4. Not paying attention to the identity of the patient, the nurse entered the information into the wrong chart, whether in paper or electronic form.
5. After reporting concerns to a supervisor or physician, the nurse did not document the name of person. The attorney may have to take many extra depositions to determine who the nurse talked to.
6. The nurse did not record care he or she provided, such as drawing blood, starting an IV, or giving a medication.
7. In long term care, the nurse recorded care as given after the nursing home resident left the building. Rote or careless charting makes the chart questionable.
8. The nurse left blanks on forms, making us wonder if the care was given and not recorded, or not given at all.
9. Illegible writing, spelling errors and lack of proofreading confused the details of care and impaired the important communication the chart was intended to provide. Lives can depend on the accuracy and legibility of chart entries.
10. The nurse used unapproved abbreviations, such as “KGH” for “keeps good health”. These abbreviations only serve to confuse others and may result in errors in interpretation.
11. The nurse used terms that displayed a negative attitude towards the patient. “Drunk”, “obnoxious”, “irritating”, and “demanding” revealed the nurse’s attitude and when coupled with a bad outcome, makes others wonder if the nurse provided good quality care.
12. The nurse accepted a questionable or incomprehensible order without questioning it. The nurse failed to question orders that he or she did not understand or feel were not in the patient’s best interest. Fatigue, distraction, and language barriers contribute to miscommunication, the number one reason for medical errors.
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