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False Documentation - Critical Incident Analysis

 The word false is dened as something you have done which is considered to be

incorrect or wrong. When we tal about nursing eld so there aren!t any chances of 

mistae is tolerable" as nurses we handle live #atients and being a nurse one small

mistae can adversely a$ect the lives of the #atients which leads to the death of 

the #atient. The main factors that are associated with this falsely act that are

#resent in this case re#ort are #ersonal negligence" heavy wor load" unfamiliarity

with the ethical law of documentation" and untrained sta$ to state a few. In order to

overcome the falsely documentation we should introduce the basic rules and

regulation of documentation and medication administration. As a matter of fact the

documentation is the bac bone of one!s sta$ that saves #atients live as well as her

own too" because if any incidents have occurred so her documentation is the only

evidence which re%ect bac to her #erformance regarding their nursing care and

res#onsibility.

During the routine clinical duty on Combined &ilitary 'os#ital (awal#indi )*th

&arch )+, at a documentation error is a signicant high ris issue for which nurses

have to be careful while administrating. ecause administrating medication is one

of the areas of the nursing #ractices in which the nurses need to be careful and

vigilant. It is a multidisci#linary #rocess" beginning at the time when doctor

#rescribes a medication continuing with the #rovision of the medication by the

#harmacist and ending with the #re#aration" administration and its documentation.

/ractice errors by nurses can cause harm to #atients" families" #ractitioners"

systems and holistically the #rofession of healthcare as well. 'ealth care setting is a

demanding #lace that lends itself to error because the fact is that humans are not

#erfect.

 The realities behind the false documentation error are lac of concentration that

leads to the attentions #rovoing. It turned out to be entirely o##osite to the

e0#ectation held from health care organi1ation. I assigned in the medical 2 surgical

ward and observation was made that rather than medication nurse other nurse was

disseminating drugs to #atients but not recording in the Intae 3ut#ut Chart

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because the medication nurse is doing documentation which leads towards false

documentation. 4imilarly one of the 5.A was administrating medication to the

#atients in order to com#lete medication tas of the assign nurse while not

documenting it as well" even though 5A is not allowed to do medication by the law

of /aistan nursing Council 6/5C7. 8#on notice" those #racticing such behavior were

confronted and informed by me" do not conduct such activities again as healthcare#roviders because it!s against the law of /5C. The #erson" who administrated the

medication" is res#onsible for its documentation and no other nurse should be

delegated to accom#lish this tas. The incident was re#orted to the 'ead 5urse who

agreed that the act was not acce#table and hat a formal meeting should be

conducted with the concern sta$ in this regard.

 This situation was highly u#setting and disa##ointing. It raised signicant 9uestions

regarding the 9uality of care being delivered to the #atients. 4#ecially when the

institutions are struggling for high 9uality assurance" and striving to attain

certication from I43. The management #aying incentives" rising salary and

a##ointing su:cient nursing sta$s to satisfy the #atient!s needs" im#rove 9uality

care and manage worload so this ty#e of error is not acce#table in any health care

organi1ation. The incident noticed is highly unethical that #ortrays a negative image

for the nursing services whole. In the following days" re%ection u#on the actions of 

the head nurse raises 9uestions regarding her actions es#ecially #ertaining to trust

issues with sta$ and wor ethics. As a sta$ member" I new the im#ortance of 

timely documentation but not ;ust the documentation matters" right documentation

at right time for right #erson and action matters a lot.

 This incident could stood out because the medication nurse was only wanted to

nish the tas. According to the national co-coordinating council for medication

error" In health care #rofessionals medication and documentation errors are very

common which need to be detected and documented for re#orting them to

overcome the #roblem. The lac of time as well as a ;ob done in a hurried manner

by the health care #rofessional can also be one of the factors that led to the nurse

to do falsifying documentation. &oreover" wor load and lac of organi1ation as a

novice could be a contributing factor for such false documentation incidents as well.

 The incident was observed during the morning which is #articularly a busy #art of 

the day when everyone is around and busy in changing their shifts. With regards to

the case" the medication nurse wanted to nish the wor as soon as #ossible

without regards to #rotocol and safety. 4he thought that by the time assigned

novice nurse would administered the medication" she could do the documentationas well to save her time but the nurse haven!t done. 4elf o#inion regarding the case

was not biased" and re%ection along with research #rovided that the in charge nurse

should have taen the rules and the regulations along with #atient safety in to

account before woring around the system and maing documentation errors.

3ther factors that can be contributing to the scenario involve many e0#lanations.

 The nurse could have been overburdened and busy or it is #ossible that the #atient

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got sic that is why she did not reali1e that she was doing false documentation.

4imilarly may it is #ossible that the nurse sim#ly was not aware of the #ossible

conse9uences of false documentation. the nurse could have been too ris oriented

and used to routine and mechanical tass that she did not thin about her role and

associated res#onsibilities. It is also #ossible that she had learned this #ractice from

other senior nurses through observation and role modeling that encouraged her to ;ust conduct documentation without medication administration. An addition factor

which leads toward this error is inade9uate nowledge about the documentation

and its im#ortant. Denver hos#ital has re#orted a death of an infant ;ust because

negligence of nursing #ractices by the allocated nurse in ,