5 Common Paperwork Errors that Harm Patients

11/12/2019

5 Common Paperwork Errors that Harm Patients

by Alana Luna, contributor

Nurses are responsible for documenting everything from patient history to changes in medication, and even mistakes that seem negligible can have far-reaching consequences. These five common paperwork errors can cause serious patient harm. Luckily, there are ways to prevent medical errors from happening, and it all starts with awareness.

1. Transcription mistakes and other typos

In the majority of everyday writing, accidentally swapping "accept" and "except" wouldn't be a big deal, but those small slip-ups can lead to gargantuan problems in the healthcare industry. When terminology is close in structure but wide apart in meaning — "hyper" and "hypo" for instance — getting them confused can exacerbate a patient's illness or worse.

Other frequent typos to watch out for include:

  • Confusing genders
  • Using the incorrect unit of measurement when recording dosages
  • Inputting the wrong code
  • Transposing the numbers on a patient ID, time code or similar sequence
  • Confusing similar-sounding medications, such as Doribax vs. Zovirax or oxycodone vs. oxycontin

2. Illegibility

The joke about doctors and bad handwriting goes back generations, but it turns out the legend is much more than a silly story. Doctor's careless, hurried scribbles contribute to more than 7,000 deaths every year. From sloppy charting to unclear instructions on prescriptions, messy writing is both prevalent and dangerous, which is one reason so many facilities are transitioning toward electronic records and prescriptions done entirely via laptops and tablets.

3. Using non-standard abbreviations

Almost everyone in the healthcare knows that q.i.d. stands for "four times daily" and that IBD is inflammatory bowel disease, but writing down WWPC in lieu of "woman with pregnancy complications" isn't a shortcut, it's confusing. There's no room for personal preferences when it comes to abbreviations in charting or other work documentation. Stick to widely accepted acronyms for safety's sake.

4. Entering information into the wrong chart

Physicians spend nearly half their time on charting and other paperwork and only 27 percent of their shifts actually interacting with patients. In an effort to shift that breakdown or to otherwise make their days more efficient, doctors may hurry through writing tasks with unfortunate results. The same goes for nurses and other professionals responsible for documentation.

Perhaps you have two Smiths on the same floor and grab the wrong chart or you're using a tablet to access electronic records and you hit the wrong tab. It's shockingly easy to enter the right information on the wrong chart, and you may not even realize it until it's too late — if you realize it at all.

5. Using subjective language

Consider objective language and vague terminology forbidden. Both carry such wide possible meanings they are essentially useless in a medical setting. What you consider "normal" may not be normal to anyone else. Saying a patient is grumpy or in pain is not nearly as valuable as saying they're exhibiting marked personality changes over the last 24 hours or that they've indicated they're an 8 out of 10 on the pain scale.

Patient observations should be recorded using quantifiable measurements whenever possible. That helps eliminate mishaps and get patients the right care as quickly as possible.

Take your time when documenting, and start each charting session by verifying you have the right chart pulled up on the computer or laying on the desk in front of you. Avoid copying and pasting — that's how incorrect information snowballs — and only write down treatments and medications administered after they've actually been given.

Preventing common paperwork errors

Practicing proper documentation means following these guidelines each and every time something is written down:

  • Ensuring the accuracy of recorded information
  • Basing documentation in fact, not opinion
  • Committing to timely charting so recollections are still fresh
  • Organizing information in a way that makes sense to everyone on the patient's team
  • Staying compliant with all applicable rules and regulations, both in-house and those set by the government (such as HIPAA)

It takes just a moment to make a paperwork-related medical error that could take much longer to unravel. By slowing down during the documentation process and adhering to accepted practices, nurses can improve their efficiency and standard of care.

Continue improving your skill set by taking on new positions at home or almost anywhere across the country. To explore your options, browse the job opportunities at NursingJobs.com.

 

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