Incomplete or Missing Documentation: Patient Safety in Healthcare

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Incomplete or Missing Documentation: Patient Safety in Healthcare

Scenario

Patient safety is among the top concerns for every healthcare set-up due to the associated negative consequences affecting care outcomes and other related issues, such as legal suits. One of the ways to ensure that patients are safe when being taken care of is by detailed documentation covering all relevant areas. However, one of my direct reports has been reported to have numerous cases of incomplete or missing documentation. This issue has caused serious problems in the care facility because it puts patients at risk. For instance, patients could be given the wrong medication leading to adverse outcomes. This issue has been brought to my attention, and I think it should be addressed conclusively to promote patient safety and enhance best practices in the facility.

Taking Corrective Action

According to Manning and Curtis (2019), there are four steps involved in solving performance problems including agreeing that a problem exists, mutually discussing alternative solutions, mutually agreeing on action to be taken to solve the problem, and conducting follow-ups to evaluate results and provide encouragement. Based on these guidelines, the first corrective action is to agree with the patient that a safety problem exists due to her lack of proper documentation when handling patients. I would meet with the nurse and explain to her the dangers of not capturing all the relevant client data, and let her acknowledge the underlying outcomes.

In the second step mutually agreeing on alternative solutions, I would seek to understand why she does not meet all the patient documentation requirements. In this case, there is no alternative to documentation; however, after knowing why she fails to follow this protocol, we could work together to solve the underlying problem. For instance, maybe she forgets that all patient data should be taken and recorded. Therefore, we could agree that she needs to start using reminders as a way of solving this problem. Solving the causal issues behind her failure at documentation would correct the situation.

In the third step, we would mutually agree on the actions that should be taken to solve this problem. As mentioned earlier, if the underlying issue is forgetfulness, then the appropriate action would be using reminders. Regardless of the problem, we would agree on a solution and lay down an action plan for the implementation of the same. This process would take place in a friendly environment using cordial language without castigating her for her actions. The purpose of the corrective action is to help her change her behavior and follow the facilitys protocols on patient safety.

The final step is to follow up to evaluate results and provide encouragement. This process is important as it assesses the effectiveness of the corrective action taken. In this case, we would meet bi-weekly and share her experience to evaluate her progress. One way of doing this is going through the documents that she has written during that period to assess whether they are comprehensive enough or they could be improved. After listening to her experience, I could then identify areas for betterment. Perhaps our strategy may not be working well for her, hence the need to re-evaluate our strategy. However, I would also let her know that she has to observe the set protocols to ensure patient safety. As such, inasmuch as I am willing to walk with her through the process, she has to play the larger role as a professional nurse and follow the guidelines, failure to which I will be encouraging incivility (Razzi & Bianchi, 2019). Ultimately, this four-step model will initiate and support the appropriate corrective action.

References

Manning, G., & Curtis, K. (2019). The art of leadership (6th ed.). McGraw-Hill Education.

Razzi, C. C., & Bianchi, A. L. (2019). Incivility in nursing: Implementing a quality improvement program utilizing cognitive rehearsal training. Nursing Forum, 54(4), 526-536.

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