In the education and professional training of nurses, doing no harm and keeping patients safe is consistently driven home as having the utmost priority. There are many aspects of maintaining patient safety, including fall prevention; however, if we were to choose two highly interconnected areas that greatly necessitate our ongoing attention and diligence, it would be the prevention of medical errors and accurate and timely documentation.
The Numbers Don’t Lie
Since the release of the Institute of Medicine’s (IOM) landmark publication from the year 2000, To Err is Human: Building a Safer Healthcare System, healthcare organizations have spent considerable energy and expense exploring, and taken action regarding, the significantly high rate of medical errors that consistently occurs in the United States.
According to patient safety experts from Johns Hopkins Medicine, more than 250,000 patients die each year in the U.S. due to preventable medical errors. Assessing hospital admission rates and other data, the researchers examined 35,416,020 hospitalizations, with 251,454 deaths resulting directly from medical errors, equaling 9.5 percent of all deaths nationally. In light of this astronomical number, Hopkins concluded that medical errors are sadly the third leading cause of death for all Americans, surpassing respiratory diseases, which kill approximately 150,000 people per year.
In terms of the actual financial cost of medical errors, research by Zegers, et al. concluded that the annual economic impact is estimated to be between $17 and $29 billion per annum. And if we take into consideration the emotional, spiritual, and societal costs of medical errors — including, among many other salient factors, families losing cherished loved ones who may also be crucial breadwinners providing financial stability — the reverberations of medical errors are incalculable.
Numbers don’t lie, and neither does the grief of millions of Americans whose suffering over the preventable loss of beloved family members can never be rectified.
Nursing Documentation: A Powerful Place to Begin
As mentioned above, timely and accurate nursing documentation is central to the maintenance of patient safety. From the first day of nursing school, novice nurses are admonished ad nauseum that if a nursing action or observation is not written down, it never happened. A nurse may absolutely know that they administered the right dose of the right medication to the assigned patient at the time specified by a provider’s orders, but without that action being documented in the proper manner, that nurse’s memory serves little purpose from a medico-legal standpoint. And while many robotic medication delivery systems may be directly linked to an electronic medical record (EMR) for automatic documentation, nurses must still take ultimate responsibility that such documentation occurred and is accurate. After all, the robot can’t be sued for patient harm, but the nurse and the facility can certainly be, and frequently are.
According to the American Nurses Association Principles for Nursing Documentation: Guidance for Registered Nurses, there are six central principles of nursing documentation, and they include:
- That nursing documentation must have the following characteristics: “Accessible, accurate, relevant, consistent, auditable, clear, concise, complete, legible/readable, thoughtful, timely, contemporaneous, sequential, reflective of the nursing process, and retrievable on a permanent basis in a nursing-specific manner“.
- That “nurses must receive adequate training and education on the various facets of nursing documentation according to professional standards, in addition to the employing organization’s policies and procedures. Training must include competency in the use of the electronic medical record (EMR) system specific to the employing institution, as well as proficiency in any site-specific software utilized. Nurses must be provided with adequate time to complete documentation.”
- That “the nurse must become familiar with organizational policies and procedures pertaining to documentation, as well as maintaining efficiency during EMR downtime, or periods of electronic system malfunction.”
- That “the medical record (paper-based or electronic) must offer appropriate security measures protecting data and patient information according to the organization, industry standards, and government mandates. This includes regulations set forth by the Health Insurance Portability and Accountability Act (HIPAA), which mandate patient confidentiality practices.”
- That “everything entered into the medical record must be accurate, valid, and complete; authenticated (factual), the author is identified, and nothing has been added or inserted; dated and time-stamped by the person who created the entry; legible/readable; and composed using standardized terminology including acronyms and symbols.”
- That “nurses should document utilizing standardized terminology to describe the planning, delivery, and evaluation of nursing care. Using standardized terminology helps with data aggregation and analysis.”
While documentation will not prevent all medical errors, its essential part in the process of error prevention cannot be overemphasized or overstated.
A Human Concern
Our patients and their families are human beings, as are the nurses, physicians, chaplains, surgeons, aides, and others who serve them. And if to err is indeed human, as the saying goes, the prevention of error is also ultimately a human endeavor and concern.
When we think about nursing documentation, quality assurance and improvement, root cause analysis, sentinel events, and the vast plethora of measures by which we strive to continually learn from and improve, they all generally have one thing in common: the pursuit of optimal outcomes, which includes decreased morbidity and mortality, patient satisfaction, and the avoidance of preventable errors. And while data sets and metrics tell us so much, safety and optimal outcomes are literally in our hands.
No healthcare provider goes to work with the malicious intent to harm another, yet harm still occurs; and while patients may fear harm — and sign waivers and agreements to that effect — they place themselves in our hands with the hope that they will exit the facility better, not worse off. Within this bond of trust steps those who work in healthcare and are sworn to do no harm. Fulfilling this promise is the least we can do, and if we can work together to prevent those aforementioned 250,000 deaths from occurring due to our errors, that is a laudable goal worth fighting for.