proper documentation....and am i over-reacting?

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[sorry, this is longer than i intended. i have to vent...]

I feel like i have to do a lot of "reporting" at my office, and it's getting really old (its not so much reporting, but me telling the back office manager/office manager/doctors/ things that have gone awry). The doctors ALWAYS back me up when i go to them about something , and they make sure there is the appropriate follow through. The office manager...not so much. I dont think she really understands the clinical side of things. We were without a Back Office Supervisor for a few months, and just had one come back in (shes an lpn), so we have her to report things to now....But i feel like I'm constantly having to point things out to supervisors...

Earlier this week one of the MA's gave a pt 3 vaccines. I was walking down the hall and saw the Doctor was in the room with the girl. She was gray and out cold. She had passed out after the MA left the room. Once the girl came to and was stable, the mom wanted to know which shots she got in which arms. I pulled her immunization record out and told her she got (shot 1) and (shot 2) and her RA and (shot 3) LA. The mom looked really confused and asked why she got stuck twice in her LA and once in her RA. I looked at her arms and sure enough, she had 2 needle sticks in her LA and one in her RA. So I asked the MA to clarify which vaccines were given and in which sites. She scribbled out on the vaccine record and changed the sites. Still 2 for the RA. I told her there were 2 sticks on the LA and please be sure of her documentation. She takes the record and changes it again.....I told all of this to the back office supervisor. i mentioned to her that she might want to talk to the MA about being careful with documentation. this MA is new with our practice...but i feel like my supervisor totally blew it off like it was nothing. she said that everyone has had documentation errors (true, but you shouldnt change..let alone SCRIBBLE... your site 3 times.).

This isnt just the only problem... The list goes on...

Long story long..... the back office supervisor isnt "supervising" us. Shes in one of the offices taking triage calls and doing ordering/other manager things. I understand she has a lot of things to do, and i am appreciative we have a her to do these things again. If im seeing these errors, i cant just ignore them. I'm looking out for patient safety. But if im always "tattling" on the other MA's, not only is it creating tension between the MA's that im "pointing out", but i feel like its not my job to be having to catch their errors. The doctors tell me im doing the right thing pointing out these errors, because its their license on the line. As MA's (or CMA in my case) we're working directly under the doctor...Im not sure what im supposed to do.....Any feedback is appreciated.:confused:

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Specializes in Emergency.

Um, sounds like some education is in order. I don't think I'd give 2 seperate shots in one arm (max vol = 1ml). Plus, if someone had a reaction, how would you know which medication caused it if 2 injections were given in one arm?

Perhaps the MA had confused the patient's right and left side due to lack of experience with site marking (ie getting the sides mixed up because it should be the patient's right/left side, not your own right/left side). She also shouldn't be scribbling out her documentation; it should be crossed out using one line, followed by "error" along with the writer's initials.

Could a standardized vaccine document be developed, which had a chart on one side which prompted the vaccine's "name, lot #, manufacturer, site administered, etc), along with a body diagram where the person would circle the cite on the drawing? Also, the back of the document could have max. volume/site listed, as well as age parameters and sites for peds.

Would it be possible for an experienced nurse come in and give an inservice on documentation?

Keep on advocating!

http://www.malenursemagazine.com/charting.html

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Specializes in SICU.

Choose your battles wisely. It is sufficient to address the party involved and let them correct there error, then go to the manager without naming names and suggest an inservice. No one is perfect, and we all make mistakes. You might find people start scrutinizing your documentation looking for your mistakes... and there will be some. It is the law of averages as we are only human. The day will come when you need one of those MAs or your peers to back you up, and you might find them reluctant to do so. Just a different perspective you may not have considered.

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I do choose my battles wisely. It used to be hard for me to "let the small stuff go", but im now able to. When it comes to patient safety though, i go forward. Shouldnt the Back Office Supervisor be doing more supervising of us in the back office to catch errors? (and yes, everyone makes mistakes).

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This is what happens when amateurs are allowed to do a professionals job. JMHO and my NY $0.02.

Lindarn, RN, BSN, CCRN

Spokane, Washington

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Specializes in med/surg, psych, public health.

Just out of curiosity...why did the MA leave the pt. alone

and also, was a VAERS done on the reactions from this pt.?

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Specializes in Med-Surg, Psych.

If you're constantly having to point out errors to supervisors, either your office is making way too many errors and/or you are going to be perceived as a trouble-maker since you are not the supervisor.

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Specializes in Med Surg, Tele, PH, CM.
[sorry, this is longer than i intended. i have to vent...]

Long story long..... the back office supervisor isnt "supervising" usin one of the offices taking triage calls and doing ordering/other manager things. I understand she has a lot of :confused:

You didn't say what your position is in this office. Are you a MA? A lot of kids have to get more than one injection per site, probably because mom has not kept up with immunizations and the kid needs them for school. She had a reaction perhaps, more than likely a vagal response to getting a shot. A lot of kids are terrified of being stuck, and I have seen many pass out. One poster mentioned the MA leaving the patient alone - she was not, she was with mom. The bottom line is that the faulty documentation was not the cause of the child's syncope and perhaps you should not have made a big deal of it in front of a patient. You may have created hard feelings over an issue that should have been handled by the LPN. The longer you are in healthcare, the more you will come to realize that it is not a perfect enviornment, will not ever be. We must strive to prevent those that do harm to the patient or jeopardize safety. For something like this I would have left a note attached to the chart that you were answering questions for mom and noticed that she documented the sites backwards, and handed it directly to the MA. If you feel strongly, see the Office Manager and tell her you have noticed a trend in errors and perhaps this should be addressed at a staff meeting - no names. If you take on the job of clinic watchdog, you make step on some toes, and find that people are watching you like hawks trying to catch you in an error. It is always your job to report problems that cause harm to the patient or another staff member, but this was neither. Next time, take it to the LPN and let her be the bad guy. I am only saying this because I had a job as a Practice Administrator in a practice with 6 docs, and we had a watchdog on our staff- a nursing student with one class under her belt and no other experience in healthcare. You can't believe the problems she created for the rest of the staff. She meant well, but 95% of the time she was over-reacting. Just pick your battles, and never embarrass a co-worker in front of a patient.

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You didn't say what your position is in this office. Are you a MA? the faulty documentation was not the cause of the child's syncope and perhaps you should not have made a big deal of it in front of a patient. You may have created hard feelings over an issue that should have been handled by the LPN. It is always your job to report problems that cause harm to the patient or another staff member, but this was neither. Next time, take it to the LPN and let her be the bad guy. Just pick your battles, and never embarrass a co-worker in front of a patient.

I stated in my first post that I am a CMA in the office. I know that faulty documentation did not cause the patient to pass out, and im in no way saying that it did. I did not make a big deal of it in front of the patient. I would never embarress a co-worker infront of another coworker or patient, because i know how awful that would feel. When I had told the mom which sites the vaccines were given in and she expressed confusion, I told her I'd get the MA to clarify. Left the room, got the MA. That's it. I talked to the supervisor without the other MA around.

Like i said earlier, its easy for me to let the small stuff go, but it does become annoying. When Im the only one pulling charts for lab reports on a daily basis (and we do have a schedule for when / who should pull them), or restocking rooms...That sort of thing its a nuisance, but it has to be done. So when i see clinical errors, but its something that doesnt harm a patient or another co-work, am i supposed to 'pretend' I didnt see it? Im not trying to be a watchdog, or the tattle-tale of the office. It's tough to watch things being done incorrectly though and not say anything. And I don't feel that its my responsibility to correct the person doing the task wrong. So what do I do?

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Specializes in peds, nursery family practice.

As a LPN supervisor with 25+years did you ever consider that your manager did handle the issue just not in front of you?? I have never disaplined any of my employees in front of their coworkers. Just because you didn't see it doesn't mean it wasn't taken care of. If you were my employee after taking care of the injection issue I would have the reprimanded you for overstepping your boundries. You had no right correcting another coworker-you should have brought the matter immediately to your manager and then let it go.:nono:

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