False Documentation 5x533v

False Documentation - Critical Incident Analysis

The word false is defined as something you have done which is considered to be incorrect or wrong. When we talk about nursing field so there aren't any chances of mistake is tolerable, as nurses we handle live patients and being a nurse one small mistake can adversely affect the lives of the patients which leads to the death of the patient. The main factors that are associated with this falsely act that are present in this case report are personal negligence, heavy work load, unfamiliarity with the ethical law of documentation, and untrained staff to state a few. In order to overcome the falsely documentation we should introduce the basic rules and regulation of documentation and medication istration. As a matter of fact the documentation is the back bone of one's staff that saves patients live as well as her own too, because if any incidents have occurred so her documentation is the only evidence which reflect back to her performance regarding their nursing care and responsibility.

During the routine clinical duty on Combined Military Hospital Rawalpindi 25th March 2016 at a documentation error is a significant high risk issue for which nurses have to be careful while istrating. Because istrating medication is one of the areas of the nursing practices in which the nurses need to be careful and vigilant. It is a multidisciplinary process, beginning at the time when doctor prescribes a medication continuing with the provision of the medication by the pharmacist and ending with the preparation, istration and its documentation. Practice errors by nurses can cause harm to patients, families, practitioners, systems and holistically the profession of healthcare as well. Health care setting is a demanding place that lends itself to error because the fact is that humans are not perfect.

The realities behind the false documentation error are lack of concentration that leads to the attentions provoking. It turned out to be entirely opposite to the expectation held from health care organization. I assigned in the medical & surgical ward and observation was made that rather than medication nurse other nurse was disseminating drugs to patients but not recording in the Intake Output Chart

because the medication nurse is doing documentation which leads towards false documentation. Similarly one of the N.A was istrating medication to the patients in order to complete medication task of the assign nurse while not documenting it as well, even though NA is not allowed to do medication by the law of Pakistan nursing Council (PNC). Upon notice, those practicing such behavior were confronted and informed by me, do not conduct such activities again as healthcare providers because it's against the law of PNC. The person, who istrated the medication, is responsible for its documentation and no other nurse should be delegated to accomplish this task. The incident was reported to the Head Nurse who agreed that the act was not acceptable and hat a formal meeting should be conducted with the concern staff in this regard. This situation was highly upsetting and disappointing. It raised significant questions regarding the quality of care being delivered to the patients. Specially when the institutions are struggling for high quality assurance, and striving to attain certification from ISO. The management paying incentives, rising salary and appointing sufficient nursing staffs to satisfy the patient's needs, improve quality care and manage workload so this type of error is not acceptable in any health care organization. The incident noticed is highly unethical that portrays a negative image for the nursing services whole. In the following days, reflection upon the actions of the head nurse raises questions regarding her actions especially pertaining to trust issues with staff and work ethics. As a staff member, I knew the importance of timely documentation but not just the documentation matters, right documentation at right time for right person and action matters a lot. This incident could stood out because the medication nurse was only wanted to finish the task. According to the national co-coordinating council for medication error, In health care professionals medication and documentation errors are very common which need to be detected and documented for reporting them to overcome the problem. The lack of time as well as a job done in a hurried manner by the health care professional can also be one of the factors that led to the nurse to do falsifying documentation. Moreover, work load and lack of organization as a novice could be a contributing factor for such false documentation incidents as well. The incident was observed during the morning which is particularly a busy part of the day when everyone is around and busy in changing their shifts. With regards to the case, the medication nurse wanted to finish the work as soon as possible without regards to protocol and safety. She thought that by the time assigned novice nurse would istered the medication, she could do the documentation as well to save her time but the nurse haven't done. Self opinion regarding the case was not biased, and reflection along with research provided that the in charge nurse should have taken the rules and the regulations along with patient safety in to before working around the system and making documentation errors. Other factors that can be contributing to the scenario involve many explanations. The nurse could have been overburdened and busy or it is possible that the patient

got sick that is why she did not realize that she was doing false documentation. Similarly may it is possible that the nurse simply was not aware of the possible consequences of false documentation. the nurse could have been too risk oriented and used to routine and mechanical tasks that she did not think about her role and associated responsibilities. It is also possible that she had learned this practice from other senior nurses through observation and role modeling that encouraged her to just conduct documentation without medication istration. An addition factor which leads toward this error is inadequate knowledge about the documentation and its important. Denver hospital has reported a death of an infant just because negligence of nursing practices by the allocated nurse in 1996. The client health-care record is an important legal document. It provides information that shows care has been provided, and it can be used to resolve questions or concerns about ability and the provision of care. Documentation provides a chronological record of the many events involving a client from ission to discharge and may be used to refresh the RN's memory. If they are required to give evidence in court, a lawyer representing an RN will often rely on available documentation to establish that the care provided by the RN was reasonable and prudent. Similarly, a client's lawyer may use the same documentation to try and show that the RN failed to meet the standard of a reasonable and prudent care provider. Learning attained from this episode pertains to the relevance and importance of documentation. Documentation is considered of significant value to the ed nurse in their daily professional work and as well as for increasing patient safety along with the liability and safety of the staff as well. In addition explorations of the potential causes for documentation were conducted to shed light on the incident. Analyzing the situation, it was learnt that nursing practices must be evidence based in order to be credible and reliable. It was realized that good documentation practice can demonstrate professional responsibility and ability which is the key component in the nursing profession.

To conclude, it can be stated that care remains the essence, the unique and major feature of healthcare professionals. Unhealthy and false documentation can put patient and staff under risk with elevated safety issued. It is therefore recommended that health care