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Cause: Penicillin allergy was not listed on the medical allergy list.

Solution: Update his chart with the allergy.

Jeannie, Lena, Hannah, Rylee

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Error #1: input/output numbers not adding up (Audrey, Anna, Dee, Rylee)

·      potential cause: documentation error / missing information (or math error)

·      solution/intervention: make sure numbers inputted right, double check fluids before charting, make sure each time the patient receives fluids, it is charted

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Error #2: didn’t document morphine given on 9/04 at 1600 (Audrey, Rylee, Dee, Anna)

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Error #2: didn’t document morphine given on 9/04 at 1600 (Audrey, Rylee, Dee, Anna)

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·      potential cause: forgot to scan off medication or didn’t give

·      solution/intervention: double check medication that’s been given

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Error #3: Inappropriate language in nursing notes (Audrey, Dee, Anna, Rylee)

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Error #3: Inappropriate language in nursing notes (Audrey, Dee, Anna, Rylee)

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·      potential cause: judgmental description or biases, possible workload, stress/exhaustion

·      solution/intervention: ask for help from coworkers, better professionalism, inter-professional accountability/communication

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Cause: Oxygen saturations are low, no supplemental oxygen is charted and continues to have low saturations

Solution: Apply oxygen, obtain oxygen order and chart appropriately

Sarah, Izzy

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Abnormal vital signs, but no flagging or notification that they were abnormal. Yes they trended down, but still no notice.

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Error #4: On 9/4 at 16:00, the 7/10 pain was not documented in the vital signs/measurements (Audrey, Dee, Rylee, Anna)

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Error #4: On 9/4 at 16:00, the 7/10 pain was not documented in the vital signs/measurements (Audrey, Dee, Rylee, Anna)

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·      potential cause: forgot to chart both the pain and morphine given for the pain

·      solution/intervention: real time documenting (document the pain and med administration when given)

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Error #5: Inaccurate nursing notes (Anna, Rylee, Audrey, Dee)

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Error #5: Inaccurate nursing notes (Anna, Rylee, Audrey, Dee)

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·      potential cause: lack of patient respiratory and ambulation assessments. The nurse documented what the patient reported and left out important assessments.

·      solution/intervention: The nurse should be assessing the patient’s status as well as asking the patient what symptoms they’re experiencing.

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1. Patient with no UOP recorded for multiple hours, and then very low urine output beyond that.

2. Chart states patient without hypertension, BP's high throughout admission.

3. In care plan, short term O2 sats should be above 92%, patient is consistently in the mid 80s to low 90s with no supplemental O2.

4. Apical pulse documented as irregular, EKG results normal.

5. Patient prescribed penicillin on admission, patient with a past medical history of Penicillin rash.

Solutions:

1. Ensure strict I&O, see if these measurements are accurate and if so investigate possible causes of low UOP, report to MD

2. Correctly interpret vital signs, obtain manual BP and ensure pt history is accurate

3. Closely monitor SpO2, follow orders, place patient on O2 to maintain saturations and decrease WOB

4. Conflict between assessment and results, be more thorough in assessing and documenting patient assessments, using diagnostics to confirm findings.

5. Patient allergy missed, notify provider of missed allergy and have a different order placed to prevent adverse reactions.

Group:

Ella N, Gracie M, Taylor M

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Goal to maintain fluid output of 30ml/hr

No interventions were made when pt was not meeting this goal

IV fluids were still running, but urine output not increasing and BUN & Creat were elevated

Nurses should reach out to provider for an order a potassium sparing diuretic

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0.9NS is being given at a very high rate for an adult. Patient is already fluid overloaded and his urine output is not adequate.

Cause: Patient was not placed on fluid restrictions, no one questioned the order.

Solution: Call the Doctor to question the order and ask about the diet.

(Rory, Olivia)

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H&H are both low and nothing was done for it.

If patient’s H&H are low that’s can contribute to him not being able to oxygenate well.

Call provider and ask what further orders to target the H&H.

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Cause: No fever during admission was charted, however in vital signs patient did have a fever. Also no Tylenol was given.

Solution: Review vitals, chart and medicate appropriately

Sarah, Izzy

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The vitals that the nurse put in the notes didn't match the ones recorded in the chart.

The nurse was lazy and didn't recheck vitals or do an intervention base on it.

The nurse should lay eyes on the patient the vitals were not updated...

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" Patient is lazy and refusing to get out of bed. VS: Stable. Nurse is begging patient to walk but still refusing. "

This is a crazy note!

Notes that are documented by a nurse should use professional language at all times and document exact situation.

Imagine being taken to court with this note??

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9/4 1600 nurse note says post-op day 1

john smith came to the ER with chest pain. what surgery did he get?

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Nursing note is unprofessional, calling a patient lazy and to just continue as planned.

Potential cause: Nurse may be rushing or frustrated.

Solution: Check documentation to make sure it is using the correct terms and has a plan for the patient even if they are refusing.

(Rory, Olivia)

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tylenol is ordered in the MAR PRN for fever and pain. Pt has 102.5F temp on admission and pain was 7/10.

tylenol was never given.

Nurse should be looking at active orders and be proactive in treating pt.

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Note says he had abdominal surgery but that is no where to be found. He came in with pneumonia and chest pain so not sure why he would have had abdominal surgery.

Potential cause: Documented in the wrong patients chart.

Solution: Double checking you are in the right chart before charting anything.

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Demographic patient information: Name misspelled, birthday doesn't exist. Potential cause - Typo. Solution - double-check charting, pay attention.

Vital signs and measurement: Oxygen device, L/min not listed. Potential cause - Oxygen not applied, despite low saturations. Solution - Place patient on 2L/min, contact doctor for further orders.

Intake and output: Times missing. Potential cause - lack of awareness, or forgot. Solution -

Medication administration: Penicillin administered Q8 instead of Q6. Solution - Verify 5 rights, double-check all aspects prior to medication administration.

Orders: No respiratory consult or oxygen orders despite his sat at 84% upon admission. Solution - Reach out to doctor and respiratory therapist immediately due to low saturation and breathing difficulty.

Nurse notes: 1500, should have placed him on oxygen. 1600 morphine was given despite no order. 2200 could have given Tylenol for fever according to order. 1000 ambulated independently prior to seeing PT, while post-surgical with previous low oxygen saturations. 1400 nursing language under the chart is unprofessional. Solutions - Utilize best nursing judgement, contact all members of the care team and obtain orders, verify current orders and pay close attention to 5 rights of medication administration.

Viv, Claire, Bry

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Nurses note made on 9/4 at 1600 refers to a post op abdominal surgery.... when/where/who/why?

Possible incorrect pt charting or giving meds without an order.

No morphine was order in the MAR but it is noted in a nursing note.

Where was the double check on this medication?

Nurses should not be giving a medication without an order.

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Patient has a penicillin allergy in his past medical history but it is not in his allergies in the chart and they are giving him it anyways.

Cause: They may not have even asked him if he has any allergies and just assumed he didn’t to save time.

Solution: Always check allergies before giving any medications and ask the patient.

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Nurse documented on 9/5 that the patients O2 was at 88% on room air and still allowed the pt to ambulate independently down the hall. Along with this the pt also had a high BP and high HR. The nurse should have provided the patient with oxygen and stabilized him before allowing him to ambulate. This should somehow be able to be flagged in the system or brought to someone's attention.

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The nurses were documenting that the patient’s vitals were stable when they were 84%-91%. Also in notes the nurse puts that the patient “tolerated ambulation well.” What does that mean? She does not report how was the patient’s breathing, and those quotations marks make it seem suspicious because it is not a quote. Same thing when it says that respiratory status is “improving”

The nurse should follow documentation and document actual patient symptoms, and how patient is doing. Should not use quotations where they should not go.

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feb 31 does not exist.

Name is spelled incorrectly

no area code for phone number

MRN # should be longer???

SOLUTION: check ID or confirm with pt

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2/31 is not a real date.

Cause: Someone was not paying attention or heard him wrong and didn’t realize it.

Solution: Take time talking to the patient and read back his information to make sure it is correct

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NKDA document but has a history of a penicillin rash?

Should we maybe confirm that he is not allergic to penicillin.

is there another ATB we could have given/ordered.

why was the order not questioned by the nurse.

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Nurses Notes on 09/4 2200

The notes state that the pt is post op day 1 for abdominal surgery. We have no other history or record that this pt had surgery. There is also documentation that the ot received Morphine but there is no order for this medication. This could be an indication that the nurse documented in the wrong chart for the wrong pt.

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education needs to be more specific and less abbreviations so that pt can understand.

education states to "stay hydrated" but pt is fluid overloaded?

this should be specified with pt and they should be put on a fluid restriction

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9/04 @1400 pt weight is 160

9/05 @1000 pt weight is 165

5 lb weight gain shows fluid retention

there should be an intervention or a flag for this weight gain.