·      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

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

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

Solution: Apply oxygen, obtain oxygen order and chart appropriately

Sarah, Izzy

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

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

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

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)

• 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.

  
  

Solution: Review vitals, chart and medicate appropriately

Sarah, Izzy

• 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??

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

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)

Potential cause: Documented in the wrong patients chart.

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

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

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.

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

SOLUTION: check ID or confirm with pt

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

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.