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Documentation errors can lead to patient harm

Documentation is among the most important tasks that nurses in Washington can perform to keep patients safe from medical errors. Elite Learning notes that a recent study revealed over 250,000 deaths annually are attributable to medical errors. By providing the right information in the right place at the right time, nurses can help eliminate or reveal mistakes and prevent serious injuries.

Here are a few of the most common documentation errors.

Leaving out information on medical charts

Nurses gather a significant amount of information about patients for health care providers, and failing to write something down could be considered negligence. Nurses should record the following:

  • Patient allergies to food and medications
  • Patient symptoms and chronic health issues
  • What actions nurses have taken and when
  • When medications are administered and what dosage
  • When medications are discontinued because of adverse effects

Putting the right information on the wrong chart

As the Nurses Service Organization points out, there are times when patient identification can be tricky. For example, there may be two patients with similar or the same names who are both on the same unit. Other potential patient confusion could involve patients with similar conditions, patients in the same room or patients with the same doctor. Recording on the wrong chart is one of the most common documentation errors nurses make.

Writing illegibly 

Notes in a patients chart have to be clear, but time constraints can lead to messy handwriting and abbreviations that do not make sense to the next health care provider who views the record. Digital record keeping may eventually eliminate this source of errors, but currently, illegible or incomplete records are in the top 10 documentation errors.