How do you chart a med or lab error

[sasha2lady]

I'm working on a ceu about documentation legal aspects. It's terrifying! I've read about all the things nurses can get sued for ranging from falls med errors abuse and fraud. My question is this, when you find or commit a med error what exactly should you chart? Example: Jon smith is out of norvasc . You can't borrow from another and the emergency kit is out.you notify pharmacy and the earliest they can get it to you is tomorrow am his dose is due tonight at 8pm. Example 2:you think you gave a resident the wrong antibiotic dose but you can't remember for sure. What do you do . Once you fill out an error form who tells the responsible party? Ex 3:you have told the aide to be sure Jonson ppa is on as he is unaware of his unsteady gait and prone to falls the aide forgets and you are in the middle of a med pass when you get to Jon only to find him lying on the floor with an obvious fx hip and a head gash you assess him and send him to the er where he dies from complications 4 days later family sues.is the aide not held accountable for herself not following instructions given by the nurse or should the nurse have to take on full heat from this incident? Now I am paranoid about whether or not my charting is any good or. Good enough is a better word for it. My handwriting is bad, always has been and I'm always in a time crunch. I don't chart at the end of my shift, I make sticky notes and flag my mar as I go and then I chart starting at supppertime . Then if something comes up I chart it. I don't chart every pen med I give I document it on the mar unless it's a nitro or someone who never complains . Have any of you ever had to go to court before and if so why and what was the outcome for all involved?

[systoly]

In the first example, no med error has been made yet, so all efforts should go towards avoiding one, such as calling DON, family or whoever maybe able to pick up the Rx. It really shouldn't be that difficult to send someone to pick it up. If it's after hours, you can get the Rx from a 24 hr pharmacy, but someone still needs to pick it up. This is one of those times when having good raport with other departments comes in handy as you could cash in a favor with the on call maintenance man if you have one. Next, the issue of not reordering in a timely manner needs to be addressed. If, for whatever reason, it turns out the Rx cannot be obtained, documenting all your steps you have taken is a must. Incidentally, it's good practice to document any phone update with family, DON or pharmacy anyway. Second example: Try to find out for sure. How many doses are left , etc. Remember to chart only the facts (you may not have any). If a med error has been made, it would be up to the DON/supervisor to decide who notifies the responsible party. Example 3 (ppa is a mobility alarm, right?): Sorry, but this is a bad one. Sure, the CNA is responsible for her duties, but the buck far from stops with her and futhermore, because the resident has a known hx of falls, the facility and the nurse have a duty to ensure the safety, such as making rounds to ensure all alarms are not only on, but also properly placed and functional. Alarms are a biggy and the responsibility cannot be solely placed on the CNA. That doesn't mean the CNA should not be subject to disciplinary action if it becomes a habbit, but blaming it on the CNA simply will not fly.

[sasha2lady]

Thanks...that helps shine a brighter light for me. It just makes me so nervous and paranoid...especially after reading my 43 pg ceu booklet on this topic. Ive been told 2 different things at work about med errors....most say dont put it in the chart just fill out the report....but another said to do both. Ive filled out a few reports over meds that were out and couldnt be obtained on my shift. I work 2nd...and we have less than half the staff that first shift does. The majority of our aides car pool because some of them dont have cars or drivers licenses. And with the fall example...Ive been lucky so far...I havent had anyone fall and die from anything to do with it. In the past 3 yrs I havent had one to fall and break a bone yet. Ive had one lady who's fell 2x and got a gash on her head and I had to send her out for sutures...both times she did the exact same thing and got the same exact gash both times. I do have one lady who fell 5x in 4 days after she was ordered a fentanyl patch...we got it stopped and put an alarm on her and now she's doing so much better about using her call bell to get us to come to her instead of trying to do things by herself all the time. I gave my aides one warning......that if I find this pt without her alarm on its an automatic writeup and if she falls one time without an alarm on its a 3 day suspension pending investigation *per the boss*. My warning must have worked because shes had that alarm on since it came out of my mouth. I know this sounds selfish but when it comes to my license and any future incidents, aside from pt safety, im solely concerned about my own license vs coworkers.

[tewdles, RN]

I was advised by an attorney and the risk manager for a large midwestern hospital to never chart that you commited and error of any type. Chart the facts but do not characterize something as wrong or in error. I have been deposed, a couple of times. My documentation was my defense...the care in both cases had occured more than 12 months prior to the deposition, so my personal memory was spotty. My charting, and the fact that I have routines, or "practice habits" that I follow to insure safety helped me to answer all questions put to me factually and honestly. Your documentation is important!