Medication Errors
This error happens when a nurse gives a medication but leaves the MAR blank.
What is failure to document medication administration?
A nurse completes a head-to-toe but never enters it into the EHR.
What is missing assessment documentation?
The nurse raises oxygen from 2 L to 4 L but does not chart the change.
What is failure to document treatment adjustments?
A critical potassium level is reported to the provider, but no documentation exists.
What is failure to document provider notification?
A fall risk screening is skipped during admission charting.
What is missing safety assessment documentation?
The nurse charts a med as given but forgets the route and time.
What is incomplete medication documentation?
A patient reports dizziness, but the nurse forgets to chart the new symptom.
What is failure to document patient-reported concerns?
Patient education is given about new meds, but no note is entered.
What is failure to document teaching?
A nurse receives new telephone orders but forgets to chart them.
What is missing documentation of provider orders?
A patient refuses bloodwork, but the nurse doesn’t chart the refusal.
What is failure to document patient refusal?
PRN Benadryl is given, but the nurse omits documenting the patient’s response.
What is failure to document medication effectiveness?
Post-op vitals are taken but not documented for two hours.
What is missing scheduled vital sign documentation?
Catheter care is completed, but I&Os are inaccurate because nothing is charted.
What is missing catheter care documentation?
Rapid Response is called, but the reason and outcome are never entered.
What is failure to document a rapid response event?
A patient falls in the hallway, but no incident documentation is completed.
What is failure to document a fall event?
Insulin is administered, but no second nurse signs off.
What is missing required co-signature documentation?
A wound is assessed but drainage, size, and appearance are not recorded.
What is incomplete wound assessment documentation?
A dressing change is done, but patient tolerance and supplies used are missing from the note.
What is incomplete procedure documentation?
Family expresses concern about worsening confusion, but no note is made.
What is failure to document communication with family?
Restraints are used, but there is no record of checks or alternatives tried.
What is missing restraint monitoring documentation?
A nurse gives a medication, charts it correctly, but fails to document the patient’s abnormal reaction afterward, leading to delayed treatment.
What is failure to document adverse medication effects?
A patient’s neurological status changes gradually through the shift, but the nurse charts only at the end, omitting the time-specific findings that could show a worsening trend.
What is failure to document ongoing, time-sensitive assessment changes?
During a blood transfusion reaction, the nurse stops the transfusion and takes all appropriate actions but fails to document the sequence of interventions and the time each occurred.
What is failure to document critical intervention timelines during an adverse event?
A provider gives multiple verbal orders during an emergency, but the nurse documents only the final order, resulting in an incomplete medical record of the decision-making process.
What is incomplete documentation of verbal/STAT provider orders during an emergent situation?
A confused patient repeatedly attempts to get out of bed, but the nurse does not document prior warning behaviors, fall-prevention measures attempted, or the rationale for implementing restraints.
What is failure to document justification and preventive measures for a safety intervention?