admitted for dehydration. It was noted that the patient should receive
heparin for thromboembolism prophylaxis. However, it was never
ordered. This statement was copied and pasted for several days assum-
ing the patient was receiving heparin. After discharge from the hospi-
tal, the patient was readmitted due to a pulmonary embolus.
Dropdown menus. It's easy to get lazy with pick list/dropdown
menus. When assessing a surgical incision, for example, there will
be several choices to make about the suture line. However, what if
there's not a choice that matches your assessment? On a busy day, if
there is nothing to click on, you might not address it. Big mistake. This
is a classic case of "Not charted, not done." Instead, enter the assess-
ment as free text in the appropriate nursing documentation section data
if the right description is not included in checkboxes or drop-down
menus.
Failing to document — or incomplete/inaccurate documentation —
can lead to patient injury and malpractice litigation. This calls to mind
a case in Florida where a woman who started to hemorrhage after
surgery had an embolization to stop the bleeding. The post-procedure
orders stated neurovascular checks to assess vascular flow. The
patient developed nerve damage due to a blood clot in the iliac artery.
She stated the nurse never evaluated her legs and was awarded $1.5
million in damages.
The margin of error with dropdown menus is razor-thin. Clicking
just a millimeter off changes the status of a patient. Take the patient
who suffered septic shock and gangrene. The nurse charted skin-nor-
mal.
Alert fatigue. It's easy for busy nurses to become desensitized
to the barrage of safety alerts and recommendations and, as a
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Medical Malpractice
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