Share you wisdom and advice

The most common failure that I see from nursing is the failure to go up the chain of command when a patient is not getting the care they need. Nurses need to do this when a physician is not responding appropriatly to phone calls or when a patient needs transfer to a higher level of care. It is inadequate to make a note something along the lines of "physician notified, no new orders" especially if calling about a critical value or vital sign. One must continue to call and notify until appropriate action is taken. I know this can be challenging when caring for other patients so try to get a supervisor involved as soon as possible.

The other thing I hate is when nurses are called in to be deposed or testify they always say things like "It's not my place to make a diagnosis" or "I only follow doctors orders" this does nothing for our profession. We are critical thinking professionals with the knowledge and judgement to know when something needs to be done.

Finally, if you are short staffed speak up. Failure to rescue is real and patients die because of inadequate nursing care.

I think you should suggest some inservice programs relating to this topic to the education department of the hospital you work at. When I was a hospital nurse, we had them yearly. There are also plenty of continuing ed courses that give updates on legal issues for nurses. As a Nurse Paralegal for a plaintiff's firm, we win quite a lot of our cases due to the lack of documentation. The old saying "if it wasn't charted, it wasn't done" is true. I'm still appalled to read nurse's notes without dates or times and flow sheets where nothing is checked off. You may have done everything right for your patient, but unless it's documented, you haven't done a thing.

SilmasRN,
I no longer work in the hospital. I have been considering offering CE through my consulting firm taylored towards RN's on malpractice. I exclusively work for the plaintiff and wish that there was a way for us to communicate common errors to providers.

Hi RN Power OHIO, I think it would be excellent if we could provide CE. Do you live in Ohio? (my husband is from Dayton). I called one DON that I knew personally here in New Orleans because we started getting a lot of clients from her hospital. I told her I was concerned about their documentation and she laughed at me. We ended up settling 3 cases from that hospital within a year. She is no longer there. The nursing community here isn't very receptive to suggestions.

There are several types of documentation mistakes other than omission. Several are"
Documenting a concerning finding but not documenting a conversation with the physician.
Writing- will monitor with no follow up note
Conflicting documentation- one nurse charts edema and another on the next shift charts none with no explanation
Overdelegation or inappropriate delagation of assessments becomes evident in nursing documentation
Computer charting - just filling in the blanks is not enough information to adequately communicate findings to other members of the team
Care Plans- are living and breathing documents that need to be taylored to individual patient needs. Care Tracks not completed or unchanged is a clue to short staffing and not modifying care as needed. Care Planning is the primary method by which nurses document the nursing process.