Wrong Pt charting

mrsboots87 · Sep 17, 2015

Did you choose this topic or were you assigned? I can't imagine there being much research in this as the solution is to read the name on the top of the screen to make sure you're in the right chart.

kristimarieSC · Sep 17, 2015

Assigned. It's kind of a bum topic, but an important one. Just need some solid sources to get through it. none of my textbooks seem to cover it and can't find much on google. boo

WCSU1987 · Sep 17, 2015

I can recall a few times it happens either similar first or last names. Biggest issue is HIPPA and issue with digital you can't truly destroy the record once it's in it's in.

Editorial Team / Admin · Sep 17, 2015

Maybe try looking into trauma patients? I once had a surgery where an entire family was in a car accident, all came in as trauma patients, but only one ended up coming to surgery. Because the patients were of a foreign nationality, didn't speak English, and no one was familiar with the names (gender typical names for male/female), there ended up being a mix up where my patient's documentation (prehospital, ER, & OR) ended up being on another family member. Unfortunately, the patient didn't make it, but there was a big to-do the next day when the mix up was discovered.

Karou · Sep 17, 2015

Anything I could contribute would just be from my experience. Contributing factors could be look alike/sound alike names, having multiple tabs/charts open at a time, or being rushed. I have documented incorrectly on the wrong patient for all three reasons. For medication documentation, an EMAR and scanners helps to prevent because it will automatically pop a warning that you have scanned a patient different from the chart you have opened. Things like vital signs are best charted one at a time on the computer in the patients room (if possible) rather than jotted down on a paper list and charted in the computer later. Less mix ups. Charting in "real time" in patients rooms in general probably cuts down on mistakes, but again that's just my experience.

That's about as helpful as I can get. You got assigned a kind of difficult topic.

Karou · Sep 17, 2015

Funny (bad) story of me screwing up. I had an admission from a nursing home and am very particular about making sure I get my admissions done. I was doing the home med section, pt had over thirty medications. I was charting them so well, so thorough, I was just beaming with pride. I was a little annoyed that the old medications entered previously were wrong and I had to take them off and add every single one from the nursing home. It took over forty minutes total.

Then when I clicked "save" I got an alert that medications I entered and took off were different from what the physician ordered this admission, and to make sure to notify the doctor. I thought huh... That's not this patients doctor.

WRONG PATIENT!!!

I about died. I had two chart tabs open and did the wrong patient! Had to correct that mess (took 20 minutes or so) then re-enter all those 30+ medications on the correct patient. I took about two hours total doing all of this. Thankfully it was a super slow night.

NEVER again have I don't that! Lol.

la_chica_suerte85, BSN, RN · Sep 17, 2015

That's a tough topic because charting on the wrong patient is not the only, or worst, error that can be done in an EHR. When safety is in question, the ISMP typically has some hidden gems on such subjects: https://www.ismp.org/newsletters/acutecare/articles/20110310.asp

There isn't a lot specifically on the "wrong patient" scenario (except the title would suggest otherwise at first glance :rolleyes: ) but it's still good info on EHR charting overall. I would pay close attention to the "wrong patient" information regarding giving the wrong meds or the wrong treatment. Yeah, I've seen nurses chart on the wrong patient because they left their previous pt's chart open but it's pretty fixable and they always caught themselves. Maybe the interventions on preventing admin of the wrong med or sending the wrong pt down for a procedure can also be helpful interventions for charting (i.e. 2 patient IDers). Charting at the bedside is one intervention I can think of specifically, especially during med admin when you're scanning the pt and the MAR catches you when you're on the wrong chart or with the wrong pt (whatever!!!).

kristimarieSC · Sep 17, 2015

Thank you all so much for taking the time to respond! I very much appreciate all of your shared stories and experiences. Yes, the actual references are difficult, but all of your input help put me on the right track! thanks again :)

HouTx, BSN, MSN, EdD · Sep 17, 2015

Hmmm - the difficulty OP is having may be due to the fact that the problem being described is NOT a healthcare issue... it is an IT (Human Factors) issue - some searching related to "user interface design" will turn up some very relevant information and research. This is a very important focus area for Healthcare Informatics.

SopranoKris, MSN, RN, NP · Sep 17, 2015

I would say another contributing factor is the EMR that "remembers" the last tab you had open. If you were just in a room with another pt, it's easy to forget to close the tab and open the correct one. I've started to chart vitals in the wrong tab, but luckily caught myself. In order to prevent this, I always close the chart every time I leave the room.

kristimarieSC · Sep 17, 2015

Thank you, additional posters!