Accurate and complete patient chart information is essential to providing the highest possible standard of care. Here are simple tips to improve nurse charting, protect patients from treatment error and prevent potential malpractice liability.
In healthcare, having accurate and available treatment information is essential for patients. During a single hospital visit, multiple healthcare professionals will make notes in a patient’s electronic health record (EHR), which can create communication gaps with lives at stake. A few common nurse documentation mistakes can lead to errors in treatment—with malpractice lawsuits not far behind.
Here are three top nursing charting mistakes, along with best practices to avoid a malpractice lawsuit, that will help keep your patients safe and you out of legal trouble.. Stay tuned for Part 2 of this list!
1. Failing to record pertinent health or drug information
Description of Error
It’s no surprise that maintaining a correct and complete medical history is vital for providing proper treatment. However, the importance of this point is further underscored by the fact that failure to record key details such as allergies, diseases, and current medications can leave nurses personally liable for negligent patient care.
In one example, a nurse neglected to note a patient’s penicillin allergy during the initial intake process. Without a proper record or indication of the allergy, a hospital intern unwittingly administered what turned out to be a debilitating and ultimately lethal dose of the drug as part of what was, by all accounts, a standard procedure. Ultimately, a single innocent nurse charting mistake had devastating consequences—the patient immediately went into anaphylactic shock and suffered irreversible brain damage. At the trial, the court found the admission nurse guilty of negligence in a case of avoidable patient death.
Asking the right questions is just the beginning. What matters most is that all relevant information ends up recorded in enough detail for subsequent hospital personnel to be able to rely on throughout the entire course of treatment. Take extra initiative to notify other staff members on rotation, make sure the information is on the patient’s identification bracelet, and comply with hospital policies surrounding EHR procedures. It only takes one nurse charting mistake to put lives and licenses at risk.
2. Failing to document prior treatment events
Description of Error
It is essential to record every detail of a patient’s treatment, especially when treating multiple patients and across shifts. Individual patient developments can seem inconsequential in isolation, but even small errors can grow the longer an oversight persists.
Take a patient coming out of surgery, for example. The day nurse observes heavy drainage from a surgical wound and changes the patient’s dressing. However, the day nurse forgets to record both the dressing change and the heavy drainage before leaving at the end of his shift. Later, the evening nurse also notices heavy drainage from the wound and checks the previous nurse’s notes for any indication of a prior dressing change.
Because the day nurse did not leave any notes indicating the patient’s course of recovery, the evening nurse considers the amount of drainage normal for a period of several hours. She too changes the patients dressing but then also omits the bandage change in the chart.
This pattern continues throughout the next day, each nurse leaving the next no indication of concern for the patient’s wound. Is the condition getting more serious? Is the patient’s life in jeopardy? No one knows because no one realizes that the patient’s wound is seeping more than it should.
The most common excuse for omissions or holes in patient chart information is a lack of time to record everything thoroughly. And while it’s true that healthcare work is often highly demanding, that doesn’t mean nurses have to compromise on quality to get everything done. There are helpful tools and strategies developed by professionals to prioritize efficiency while maintaining quality care.. One efficient practice involves flow sheets that can be included in the patient EHR at the end of a shift. Leverage hospital standard flow sheets whenever possible, and ask where to find them in the EHR system if you can’t locate them easily.
3. Failing to record that medications have been administered
Description of Error
Lifesaving drugs can all too quickly become life-threatening when administered improperly—either through overdose or adverse interactions. It is key to record every medication given to the patient over the entire course of treatment, including the dose, route, and time of each administration.
For example, a day nurse once gave a patient heparin by intravenous push just before she went off duty. An hour later, the evening nurse saw that an order had been placed for heparin, but no indication that the medication had already been given. The evening nurse then proceeded administer the full dose once again, causing the patient to hemorrhage to the point of hypovolemic shock. Fortunately. the patient survived the ordeal, but he went on to successfully sue the hospital for malpractice in administering an entirely avoidable overdose.
Both nurses made mistakes in this situation. The day nurse should have recorded that the patient had received his medication. Furthermore, the evening nurse should have been suspicious of the heparin order with no indication that the dose had been administered. In this scenario the nurse could have protected both the patient and the hospital by taking a few simple steps to mitigate risk to the patient. Asking the patient if they have received their medication, confirming with the hospital pharmacy about whether or not the medication had been furnished, or even reaching out the previous nurse directly all could have prevented the more perilous error and subsequent lawsuit.
As a rule of thumb, nurses should avoid making assumptions when they notice gaps or missing information in a patient’s treatment documentation. Healthcare professionals have exceedingly demanding schedules, but it’s always better to take the time and double-check the details than to make assumptions and be wrong.
Curious for more nursing documentation errors to avoid? Check out Part 2 of this article!