Avoid these Charting Mistakes and Reduce Risk of Medical Errors

Avoid these Charting Mistakes and Reduce Risk of Medical Errors

Failing to document care or making errors in documentation, medications administered, and other aspects can affect patient care and lead to liability issues for healthcare providers.

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According to Johns Hopkins safety experts, medical error is the third highest cause of death in the U.S. A 2016 report based on an analysis of medical death data by the team revealed that every year, medical error causes more than 250,000 deaths in the U.S. Improper documentation is one of the main causes of medical mistakes. As an experienced medical transcription company, we fully understand that failing to document or making errors in documenting the patient's condition, medications administered, and other aspects can affect care, and lead to litigation liability issues for the healthcare organization and the physicians and nurses responsible for providing care.

Today, electronic health records (EHRs) make it easier for providers to maintain patient charts and documentation. However, digital record-keeping can also result in errors if proper practices and procedures are not followed. A recent report published by Advance Healthcare Network discusses common documentation mistakes that healthcare providers should be mindful of as well as strategies to support correct record keeping. •

Not recording medications administered: Medical transcription services can ensure documentation of medication orders as prescribed. However, it is the responsibility of nurses to ensure the correct medication is given to the correct patient, record every medication given to the patient when it’s administered, in the correct dosage, via the correct route, and timed correctly. Lack of proper documentation for any medication can result in an error. For instance, not documenting a needed medication in its proper dose can result in the wrong dosage being administered by another provider since no previous documentation is available. Reading the prescription label and expiration date of the medication is also a best practice.

Experts recommend that if the nurse observes that a patient has received a medication that has not been documented, she/he should check with the current staff about the medication given.

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Failure to record important patient information: Suppose the patient has a food or drug allergy or a chronic disease such as diabetes. Failure to record this pertinent

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information on the chart can compromise care and patient safety and lead to charges of negligence. Patients should be asked about their allergies, diseases, and chronic health problems and the information should be properly recorded in the admission sheet and notes. A best practice would be to put labels on the patient’s chart to alert other providers about these issues, especially drug allergies.

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Not recording all nursing actions: In a busy working day, nurses perform many actions and sometimes fail to record them properly. Failure to ensure clear and accurate nursing records for each patient will result in incomplete handover to the next team of nurses. For instance, not recording administration of a medication can increase risk of dosage or treatment being duplicated or omitted. A practical strategy to resolve this problem is to insert flow sheets in the patient’s chart at the end of each shift for review and follow up by caregivers down the line.

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Recording on the wrong patient’s chart: Confusion between two patients can occur when they have the same name, same room, same condition, or same doctor. This can lead to recording on the wrong chart. A physician’s confusion of two patients' records is considered malpractice, and not ordinary negligence. Providers have to be extremely vigilant about situations that lead to confusion between patients as it can lead to wrong administration of medication or even a wrong procedure being performed. Strategies to avoid this mistake include flagging the patients’ names on charts and medication records and checking wristbands before giving medications.

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Not documenting discontinued medication: If a medication is no longer being taken, the entry should be marked discontinued. It may happen that the patient has been taken off the medication because of its adverse effects. If discontinued medication is not documented, it could put the patient at risk of developing another medical condition. To avoid this, nurses on each shift should double check and review all new orders to ensure each patient’s order is noted and transcribed correctly on the physician’s order and the medication administration record (MAR) or the treatment

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administration record. One solution would be to have a chart flag process in place to draw attention to charts with new orders that require order verification.

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Making errors in transcribing orders: Wrongly transcribing a drug dose or unintended omissions in the transcription of drugs can lead to prescribing faults, erroneous medical decisions, and harm to patients. Nurses need to be familiar with medications, procedures, and activities and be able to recognize an order that may be wrong. Missing a decimal point in prescriptions can have disastrous consequences for the patient. For instance, “Coumadin 1.0 mg” can wrongly transcribed as “Coumadin 10 mg”. Experienced transcriptionists in medical transcription companies would ensure that such mistakes are not made and check with physicians if they have any doubts before documenting the order.

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Making copy paste errors in EHRs: A 2017 National Institute of Standards and Technology (NIST) report warned that using the copy and paste function in EHRs presents significant safety concerns. The researchers found that although EHRs’ copy and paste functionality meant to allow medical practitioners to easily and efficiently reuse information in patient EHRs without having to retype the information, in practice, this functionality has introduced overwhelming and unintended safety-related issues. The study recommended that EHR developers should make specific changes to the use of the copy paste function to avoid user errors related to allergies, discharge summaries, medication entries, surgical notes, and vital signs. The study’s recommendations, as reported by the Advisory Board, are that EHR systems should:

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Allow users who are copying and pasting information between different patients' EHRs to easily transition between charts "with unrestricted access to input information to another chart" by a user's deliberate action;

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Ensure that all data copied and pasted from surgical notes is, in fact, copied and pasted and allow users to edit the data; and

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Ensure that when users are copying and pasting information between different patients' EHRs, the users know which patient's EHR they are accessing at any given point.

Physicians and nurses are focused on providing safe and efficient patient care, but inadvertent medical errors can occur. Paying attention when charting and documenting care can help minimize the risk of medical errors and reduce the chances of facing liability litigation.

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