Proper documentation in healthcare settings is of utmost importance as it can impact patient outcomes and create liability issues for the facility, physician and nurses involved. Neglecting to document a patient’s condition, medication administration, or other aspects of care can lead to negative consequences. Here we will explore some of the useful insights on different types of documentation errors in healthcare settings:
- Incomplete or missing documentation is a prevalent issue in MAR charts and other documentation systems, and it can have significant consequences for both patients and healthcare providers. When healthcare providers use vague or ambiguous terminology such as “ unspecified”, crucial information may go missing from the medical chart. This missing health information could potentially harm the patient. Incomplete MAR chart medication documentation can also lead to problems with medical audits and insurance claims. For instance, auditors and insurance companies may scrutinise medical records to ensure that medical necessity is adequately documented. If documentation is incomplete or ambiguous, it could result in claims denials and financial losses for healthcare providers. Furthermore, incomplete documentation can lead to misunderstandings between healthcare providers, resulting in a lack of continuity of care. It may also cause delays in treatment, misdiagnosis and medication errors, which can harm patients’ health and well-being.
- Abbreviations are a significant concern in both paper and electronic documentation in healthcare. The improper use of abbreviations can lead to confusion, misunderstandings, and errors, which can negatively impact patient care and outcomes. For instance, the abbreviation “q.i.d” may indicate that a medication is to be taken four times a day, while “q.d” signifies a once-daily dosage. Such a mix-up can lead to incorrect medication dosages and adverse drug reactions. Similarly, “HS” can mean both “Half strength” or “At bedtime”.
- Typographical errors in medication documentation can have serious consequences for patient safety. These errors can occur when healthcare providers enter medication names, dosages, or other critical information into MAR charts or other documentation systems. One common type of typographical error is the omission or addition of a decimal point, which can result in significant dosing errors. For instance, if a decimal point is missed when documenting a medication dose, the patient may receive ten times the intended dose, leading to overdose and adverse effects. On the other hand, if an extra decimal point is added, the patient may receive a tenth of the intended dose, which may be ineffective in treating their condition.
- Confusing similarly spelled medication names is a documentation error that can lead to serious patient harm. Medications with names that look or sound alike can be easily confused, especially when healthcare providers are under stress or time pressure. Here are some other examples of medications that have similar names and can be confused due to spelling errors:
- Fentanyl and Fentora: Fentanyl is a potent opioid medication used for pain management, while Fentora is a brand name for a formulation of fentanyl used to treat breakthrough cancer pain. Confusing these medications can lead to incorrect dosing and overdose.
- Lamictal and Lamisil: Lamictal is an anticonvulsant medication used to treat seizures and bipolar disorder, while Lamisil is an antifungal medication used to treat skin infections. Confusing these medications can lead to inappropriate treatment and delays in managing the correct condition.
- Zantac and Zyrtec: Zantac is a medication used to treat acid reflux and heartburn, while Zyrtec is an antihistamine used to treat allergies. Confusing these medications can lead to ineffective treatment and increased risk of adverse effects.
Planning to implement eMAR in your caregiving facility?
Implementing an electronic medication administration record (eMAR) system can bring many benefits to your organisation. An eMAR system can help reduce medication errors, improve medication adherence, and streamline medication administration processes. To know more on how eMAR can benefit your care home, check this useful read.