Perhaps there is no time that requires more trust than when you are in the hospital. If you are injured, having surgery or experiencing a medical crisis, you must rely on those with appropriate medical training to provide adequate care and monitoring of your condition.
Those at the forefront of this obligation are nurses. Most nurses are skilled and dedicated to their patients. Their diligence and attention to detail can make your hospital stay as comfortable as possible and may even hasten your recovery. However, it may only take one careless nurse to cause a domino effect of mistakes, especially if that carelessness is reflected in the nurse’s charting of your care.
Common mistakes that place you at risk
Patient charts are a roadmap to recovery. When a nurse comes into your room, the first thing he or she may do is check your chart. The information in your records tells the nurse how you fared through the night, whether your vital signs were stable and what kinds of medication you received. Without this information, a nurse or attending doctor may unintentionally make an error that could result in devastating injury to you. Unfortunately, some common charting mistakes include these:
- Failing to include in your chart all relevant information about your health, allergies and medical history
- Putting your information in another patient’s chart or recording another patient’s information in your chart
- Forgetting to record that you received medication
- Failing to double-check if your chart does not show that a nurse on a previous shift administered medication that a doctor prescribed
- Neglecting to note if you experienced a negative reaction to a medication
- Forgetting to record when a doctor orders the discontinuation of a medicine you had been taking
- Failing to notice or record any decline in your condition or symptoms that may be cause for alarm
- Transcribing the dosage of medication a doctor orders for you or neglecting to question if a doctor orders a dosage that seems inappropriate
While many Massachusetts hospitals and medical centers have their patient charts on computers or tablets, this does not eliminate all potential for errors. The answer is for every nurse to take the time necessary to carefully enter all your information in a timely manner and verify if any information in your chart seems unusual or confusing. If this did not occur in your situation and charting errors have left you injured, you have the right to obtain information and guidance about your legal options.