Jean Watson Nursing Theory
Mislabeling of Medical Orders, Stuffing Charts
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
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
References: Courtney James Boyer Edward 2008 Case Files of the Universtiy of Massachusetts Fellowship in Medical Toxicology: Lethsl Dose of Opioids Contained in a Elastomeric Capsule Labeled as Vancomycin.Courtney, James, Boyer, & Edward (2008). Case Files of the University of Massachusetts Fellowship in Medical Toxicology: Lethal Dose of Opioids Contained in a Elastomeric Capsule Labeled as Vancomycin. Journal of Medical Toxicology, 4(3), 192-196. Retrieved November 4, 2011, from http://login.lib-proxy.uis.edu/login?url=http://search.proquest.com.lob-proxy.usi.edu/docview/196342901/ Dunn Edward Moga Paul 2010 Patient Misidentifcation in LAboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration.Dunn, Edward, Moga, & Paul (2010). Patient Misidentification in Laboratory Medicine: A Qualitative Analysis of 227 Root Cause Analysis Reports in the Veterans Health Administration. Archives of Pathology & Laboratory Medicine, 134(2), 244-255. Retrieved November 6, 2011, from http://login.lib-proxy.usi.edu/login?urt=http://serach.proquest.com.lib-proxy.usi.edu/docview/211049761 Dunn Edward Moga Paul 2010 Patient misindnetifcation in laboratory meidicne: A qualitative analysis of 227 root cuse analysis roeports in the veterans health administration.Dunn, Edward, Moga, and Paul (2010) Yoder Wise 2011 Leading & Managing in NursingYoder, & Wise (2011). Leading & Managing in Nursing (5th ed.).