Chart checks

[maelstrom143]

In our facility we do chart checks; days do 12h checks, nights do 24h checks.

Recently I came across a patient sent to me who had a 12h chart check already done. Being the cynic that I am, I began reviewing orders so as to know what was the plan and ensure orders had been placed properly. What did I find? A chart where nary one order had been noted off, errors in a couple of orders, inaccuracies in medications this patient was supposed to be getting (i.e. Lasix and KCl had been completely forgotten, Norvasc never ordered...).

Needless to say, I promptly went to the beginning of the orders (patient admitted in the am, so not too many pages to traverse) and, one by one, began reviewing and noting off orders as I verified they were correct (this is the way ALL my chart checks are done...each and every order will be reviewed by me before I sign off a 12h chart check).

When I was done, I called the nurse who gave me the patient and told her what I had found and how she should never sign off a chart check unless she had been able to do the chart check, as this can be written up and is dangerous. She told me, "go ahead and write me up. I did the best I could." Seriously? This shoddy work is the best you could do? How did you pass nursing school? Good God! How do you survive?

What I said was, "I do not have the time or desire to write it up. I am giving you a heads up that this is not right, not safe, and can get you in a lot of trouble, as it is considered falsification of documents, as a chart is a legal document. Please, next time if you cannot do the check, remember: we have 12h...if you are transferring the patient and do not have time to check the chart...DON'T. Tell the nurse getting the patient and let her do what needs to be done. We have until the end of the shift."

It still bothers me. When did we lose sight of accountability and responsibility? When did we stop caring whether or not we let errors slip right past us? When did we stop trying to do what was right just because it is the right thing to do, not because someone is watching us?

[CoffeePVCs]

Yikes! That is scary. It's also scary when an order gets taken off under one impression but another nurse reads the order differently. My last nursing clinical in school was with a facility that implemented 100% computer documentation and the physicians had to enter their own orders and it goes straight to pharmacy electronically. Hopefully with everyone going in the direction of electronic charting, it will minimize that errors.

[maelstrom143]

Yikes! That is scary. It's also scary when an order gets taken off under one impression but another nurse reads the order differently. My last nursing clinical in school was with a facility that implemented 100% computer documentation and the physicians had to enter their own orders and it goes straight to pharmacy electronically. Hopefully with everyone going in the direction of electronic charting, it will minimize that errors.

I can't wait for the day. It will make things so much easier when we are no longer guessing what the heck the doc ordered (having three people deciphering a doc order is no joke o.O)

It just scares me. As we age, the risk of us ending up as a patient increases and what I see at times scares the daylights out of me. I feel I work for a pretty squared away hospital, but sometimes the individuals that are supposed to make sure things are as they should be drop the ball :/

[Aeterna, BSN, RN]

My mind is boggled when a nurse is apathetic about a mistake he/she made! If someone tells me about an error I have made, I'm genuinely horrified. I have yet to see a nurse be apathetic about their mistakes when I tell them, but I have heard stories from others.

[iluvivt, BSN, RN]

I used to do chart checks on every single chart when I did charge and I usually found some errors. Now we have all computer orders except for chemotherapy and TPN which must be hand written and it has greatly decreased the error rate. The problem here is the apathetic nurse..you sure were exceedingly professional in your dealing with her. I think when I realized the extent of her basically "not giving a d###" I would have brought it a little closer to her home by asking her if she would think it acceptable if it was her or a loved one receiving the substandard care. She did get defensive and may not make the necessary changes. Often when I could write something up I decide to do some teaching instead and if when approaching the nurse in a caring professional to professional manner they can take in what I am saying and care about making an improvement or following the policy..ect...I will not do the write up b/c I think we get a bit crazy on those sometimes..BUT if I got the response you did.I would have to say I would write it up.

[HouTx, BSN, MSN, EdD]

I completely sympathize/agree with the OP's point of view. What we are dealing with in these instances is not limited to the nursing profession.. some people just have never developed a higher-level moral compass & probably never will. Take a look at Kohlberg's theory of Moral Development Kohlberg Tutorial for more insight. Once you have this frame of reference, it's pretty scary to realize how much of society is still operating on a Stage I level.

[Double-Helix, BSN, RN]

Does a 12/24 hour chart check entail checking ALL of the orders (since admission) and verifying they are correct? Simply the name, "24 hour chart check" assumes that only the past 24 hours worth of orders are reviewed. In our hospital, a 12 hour chart check involves checking the past 12 hours of orders with both nurses. We do them at each shift change and both the receiving and the endorsing nurse sign the chart check.

What's your policy state? Did you find these errors within the past 12 hours? Is it possible that the other nurse only checked the past 12 hours worth of orders, which were correct, not the entire chart?

It's possible that the way you addressed the situation also upset your co-worker. After all, it was probably a fairly lengthy process for you to check the entire chart. Then, to call your co-worker at home (when she may have been asleep or trying to spend time with family) just to inform her about the mistakes she had made, probably didn't go over too well. Personally, I hate being called about work when I'm off if 1. It's not an emergency and 2. There isn't anything I can do to rectify the situation. It would have been best to report this to your supervisor and allow her to address it with the employee the next time she came to work, rather than you taking admonishing into your own hands.

[maelstrom143]

ashley, picu rn said:

"does a 12/24 hour chart check entail checking all of the orders (since admission) and verifying they are correct? simply the name, "24 hour chart check" assumes that only the past 24 hours worth of orders are reviewed. in our hospital, a 12 hour chart check involves checking the past 12 hours of orders with both nurses. we do them at each shift change and both the receiving and the endorsing nurse sign the chart check."

[color=#b22222]our 12h chart checks involve reviewing the last 12h of orders to ensure we have not missed an order or made an error in how it was ordered, in addition to ensuring meds are accurate.

ashley, picu rn said:

"what's your policy state? did you find these errors within the past 12 hours? is it possible that the other nurse only checked the past 12 hours worth of orders, which were correct, not the entire chart?"

[color=#b22222]unfortunately, no, it is not possible.

this particular patient was admitted through the ed that am. he hit the floor @ 1000h. the nurse who admitted him to her area transferred him to me @ 1700h.

ed never reviews admission orders. it is the responsibility of the nurse admitting him (in this case the nurse who sent him to me) to review his admission orders for accuracy and follow through, especially since for a dx of cp many of the orders are considered stat, in addition to noting them off as she reviews them (my admissions/chart check for new admits must be done within a 2h window due to this issue).

this also leads me to another huge error that led to this patient not receiving his ca++ channel blocker, diuretic, or potassium. his admission meds were incomplete and inaccurate, so when the doctor ordered the meds to be given based on the "admission pta meds" that was supposed to be reviewed by the nurse w/the patient for accuracy, he failed to re-order the missing lasix, kcl, and norvasc (chfer w/prior mis, cabg, etc, in a-fib). not to mention how aggravated the patient and his wife were with me when i began asking them about home meds and reviewing the information to correct omissions/errors.

ashley, picu rn said:

"it's possible that the way you addressed the situation also upset your co-worker. after all, it was probably a fairly lengthy process for you to check the entire chart"[color=#b22222]

(i was respectful, but felt obligated to inform her the chart checks must not be signed off if not done (this is a legal document and signing for what one did not do constitutes fraud, although i did not bother to mention this during my conversation w/said nurse).

[color=#b22222]

in our step down unit that day, my fellow rn and i answered our own phone and entered our own orders (protocol for this unit), and did 1:1 care for our patients (cna off sick). [color=#b22222]

to review admission & correct omissions and errors, do a head to toe, do the chart check, call the doctor to get a corrected med list order (while taking care of my other patients) it took me till 1830h, approximately 1.5h). unlike us, her unit has a secretary and i know they had several cnas that day.

ashley, picu rn said:

"then, to call your co-worker at home (when she may have been asleep or trying to spend time with family) just to inform her about the mistakes she had made, probably didn't go over too well."[color=#b22222]

we are day shift. she was still on the floor [med surg].

it is good to have family to spend time with...it is even better if that family is safe, which may not be the case if they end up ill, being cared for by an individual that does not take his/her duty seriously[color=#b22222].

ashley, picu rn said:

"personally, i hate being called about work when i'm off if 1. it's not an emergency and 2. there isn't anything i can do to rectify the situation. it would have been best to report this to your supervisor and allow her to address it with the employee the next time she came to work, rather than you taking admonishing into your own hands."

[color=#b22222]i was the charge nurse in my area at that time. furthermore, as an rn, i am within my scope of practice to address an issue at the lowest level, since it was a series of errors and may have led to patient harm due to the medications and procedures that were entered incorrectly. i would prefer not to do an incident report, as i had caught and corrected the errors, so no issues. if i screw up that badly, please call me at home and let me know so that next time i will be more conscientious in my duty.

errors at a restaurant will get you an irritated patron, maybe a loss of business from that particular diner. an error in our profession can cause harm to another human being...that human being matters to someone out there; he/she is someone's lover, father, mother, child.

they place their safety and their trust in our hands.

when we no longer care enough to honor their faith in us, it is time to get out of the field and go do something less dangerous to others, like washing cars or doing dishes.

after all, if we no longer care, then we are truly being overpaid for our services.

[maelstrom143]

I completely sympathize/agree with the OP's point of view. What we are dealing with in these instances is not limited to the nursing profession.. some people just have never developed a higher-level moral compass & probably never will. Take a look at Kohlberg's theory of Moral Development Kohlberg Tutorial for more insight. Once you have this frame of reference, it's pretty scary to realize how much of society is still operating on a Stage I level.

Wow. Thank you for the link. Very cool :) and I totally agree.

I am fortunate to be surrounded by caring people that I am proud to call friends and family, but it is very scary to me that so many people do not believe in being held accountable for their actions. In many people's opinion, it is not their problem and they did no wrong, it is everyone else's fault.

[caliotter3]

This is no different than any other task that is not done at all, whether charted or not, or any other error of omission or commission. A week ago, I threw out a bottle of medication that had been placed in use midway through November of last year. The bottle contained doses for 60 days. What is it now, July of the following year? Looking at the labeling, the medication expired in February of this year. I see no point in speaking, nurse to nurse, to the responsible nurses. This is not the first time I have discovered that they don't give meds. If I tell the boss, who gets reamed? Yes, of course, I do. Not the nurses who don't think they have to make the effort to administer ordered medications. After all what is night shift for? Certainly, nothing to do with giving meds. That's a task for others to worry about. I get so fed up.

[Maremma]

Caliotter3 I am trying to be sure I understood what you have written here. Are you saying that if you told your supervisor about the pills that were not administered you would be yelled at because "you should have caught this earlier"? Is it the overnights job to be checking for expired meds every night?

I am not suggesting that you do not have nurse's at your job that are not giving meds but signing that they are. I also have that problem where I am at. I am just wondering how supers justify ignoring problems like this where you are.

Was the bottle never even opened? Is it possible your pharmacy sent another bottle after the end date for the original prescribed length of treatment with said drug?(we had this problem with our pharmacy and a particular drug.)Patient had already taken the full course of med prescribed. They for some reason sent us another round of this med. I sent it back to them and they kept sending it back to us even though the patient was discharged and the were repeatedly notified! Is that how the super would justify ignoring that you are saying the meds were never given in the first place?

Was it possible the med came and then the order to administer the drug was D/C'd before it even got started? We have also had that happen. An on- call Dr prescribed something and the regular Dr wanted something else. It is already dropped off before regular Dr comes in or calls. Or the on call Dr prescribes something hospice doesn't approve or pay for etc.

Is it because the problem is "to old" and so the super now sees it as better to "brush it under the carpet" so she doesn't have to try to explain what took so long to even find the problem in the first place?

In our facility it is EVERYONE'S job to keep all meds dated and expired meds out of the cart. We would ALL get in trouble if the pharm rep found them on her monthly rounds. Do you not have anyone that audits your med carts or did they just not audit yours for to long a time? Not that it would necessarily help. It may make things worse for the signing but not giving. the "evidence" would be removed without solving the actual problem if you do not also have to "send back" to pharmacy unused or expired meds.

[imintrouble, BSN, RN]

There are no 12h checks where I work. Only 24h. Therefore, night shift is responsible for errors that are not caught. In other words, day shift gets a pass if they make a mistake, because night shift should have caught it.

It has never been acceptable to me in all the years I've worked at my facility.

But that's the way it is.