Phyllis A. Harman
University of Southern Indiana
Mislabeling of Medical Orders, Stuffing Charts
Describe the Situation and How Handled
A patient was admitted to the medical surgical unit for the emergency room. New admissions require labels and a demographic printout be printed and accompany the patient to the unit. This unit uses electronic charting as well as paper charting for the physicians. The paper chart contains; blank medical orders sheets for the physician, printouts of lab, and X ray results, discharge orders, medication orders, history and physical, and do not resuscitate orders. The charts have dividers for each section and the sheets are labeled with the patient’s identification labels. The patient was admitted to the unit as per policy. A copy of the admitting orders and medication orders were distributed to the admitting nurse on the unit. A medication was to be administered to the patient after admit to the unit was complete. The nurse looked at the order for verification and the patient identification to double check before administering the medication. When checking the physician order, against the patient identification the nurse identified an incorrect patient label had been placed on the physician order sheet for the medication. The order sheet had already been faxed to the pharmacy and placed in the patient’s chart. The mistake was brought to the attention of the unit manager immediately, leading the way for a new policy and procedure for labeling patient documents, storing labels, and stuffing charts. The event that occurred could have led to a sentinel event by administering the wrong medication and causing harm or death to the patient. The incident could have had an effect on all the areas that care for the patient. The manager of the unit quickly notified the pharmacy, the nurses on the unit, the patient’s physician, and the unit coordinator. The chart was quickly reviewed for any other mislabeled information as well as the other charts on the unit at that time. The manager formed a team from the staff on the unit to conduct a root cause analysis using the Ishikawa or fishbone diagram. Describe and Analyze Theory/Style
The management style used on this unit was transformational leadership. This leadership style used by the manager empowered the employees to participate in the unit by open communication, promoting new or better ideas and feeling part of a team. The five principles of this style of leadership were used as the team was formed and the process of change was recommended, the five principles of transformational leadership: Yoder and Wise (2011, p. 40) 1. Challenging the process
2. Inspiring a shared vision
3. Enabling others to act
4. Modeling the way
5. Encouraging the heart
The use of these principles helped the manager to include all the members allowing them to see they were part of the solution and not part of the problem. The unit already had a policy in place for labeling, storing and stuffing charts. The manager and the teamed challenged the process already in place to prove a better way to provide this service reducing the risk of this event reoccurring. Inspiring a shared vision from the team formation, allowed them to act on the situation, model a new and improved way of performing these tasks and encouraging others to have the confidence to speak up and participate in events allowing them to build confidence as professionals.
The occurrence of mislabeling orders or patient information has been an issue in all facets of the hospital environment, a study from the Dunn, Edward, Moga, and Paul (2010) showed this affected lab specimens as ours affected the patent physician orders. This showed this event was not limited to just one area of patient care but all areas could be affected. The study reviewed 227 root-cause analyses by the team involved. They all shared the vision of making...