When you’re working with multiple patients, it’s absolutely essential that you chart information about them correctly. A number of nurses may be assigned to the same patient over time, so having an accurate chart is of the utmost importance.
Charting mistakes may lead to a patient receiving a double dose of a medication or not getting one at all. It may result in a patient receiving a medication that they’re allergic to or cause them to go through a test a second time because of failing to document a previous treatment.
Charting mistakes may lead to malpractice claims
Since it’s so important to keep detailed charts, forgetting to chart procedures or medications given to the patient could lead to a negligence or malpractice claim if the patient is harmed as a result of those actions. For example, if the patient was supposed to receive a dose of insulin following a surgery but that injection wasn’t noted, a second dose might be given. This could lead to life-threatening hypoglycemia for a diabetic patient.
Nurses who notice that there is a gap in information should reach out to the previous nurse on duty to ask if they completed their charts correctly. If they cannot be clear with an answer, then it is reasonable to reach out to other departments, like the pharmacy or imaging departments, to see if the patient had the medications or examinations that were expected that day.
In a worst-case scenario, the nurse on duty could ask the patient if they know if they received their medications or had tests done that day. This won’t always be possible if the patient is asleep or otherwise unable to communicate, but when it is possible, this step could help protect the patient.
If you make an error when charting, you may need to defend your license
Nurses make mistakes because they are human. However, those mistakes could put people’s lives at risk, so they can’t be taken lightly. If you made a mistake that led to injuries or death, you will need to defend your nursing license to protect your career.
