False Documentation - Critical Incident Analysis

The word false is defined as something you have done which is considered to be
incorrect or wrong. When we talk about nursing field so there aren't any chances of
mistake is tolerable, as nurses we handle live patients and being a nurse one small
mistake can adversely affect the lives of the patients which leads to the death of
the patient. The main factors that are associated with this falsely act that are
present in this case report are personal negligence, heavy work load, unfamiliarity
with the ethical law of documentation, and untrained staff 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 back bone of one's staff that saves patients live as well as her
own too, because if any incidents have occurred so her documentation is the only
evidence which reflect back to her performance regarding their nursing care and
responsibility.

During the routine clinical duty on Combined Military Hospital Rawalpindi 25th
March 2016 at a documentation error is a significant high risk issue for which nurses
have to be careful while administrating. Because administrating medication is one
of the areas of the nursing practices in which the nurses need to be careful and
vigilant. It is a multidisciplinary process, beginning at the time when doctor
prescribes a medication continuing with the provision of the medication by the
pharmacist and ending with the preparation, administration and its documentation.
Practice errors by nurses can cause harm to patients, families, practitioners,
systems and holistically the profession of healthcare as well. Health care setting is a
demanding place that lends itself to error because the fact is that humans are not
perfect.

The realities behind the false documentation error are lack of concentration that
leads to the attentions provoking. It turned out to be entirely opposite to the
expectation held from health care organization. I assigned in the medical & surgical
ward and observation was made that rather than medication nurse other nurse was
disseminating drugs to patients but not recording in the Intake Output Chart

because the medication nurse is doing documentation which leads towards false
documentation. Similarly one of the N.A was administrating medication to the
patients in order to complete medication task of the assign nurse while not
documenting it as well, even though NA is not allowed to do medication by the law
of Pakistan nursing Council (PNC). Upon notice, those practicing such behavior were
confronted and informed by me, do not conduct such activities again as healthcare
providers because it's against the law of PNC. The person, who administrated the
medication, is responsible for its documentation and no other nurse should be
delegated to accomplish this task. The incident was reported to the Head Nurse who
agreed that the act was not acceptable and hat a formal meeting should be
conducted with the concern staff in this regard.
This situation was highly upsetting and disappointing. It raised significant questions
regarding the quality of care being delivered to the patients. Specially when the
institutions are struggling for high quality assurance, and striving to attain
certification from ISO. The management paying incentives, rising salary and
appointing sufficient nursing staffs to satisfy the patient's needs, improve quality
care and manage workload so this type of error is not acceptable in any health care
organization. The incident noticed is highly unethical that portrays a negative image
for the nursing services whole. In the following days, reflection upon the actions of
the head nurse raises questions regarding her actions especially pertaining to trust
issues with staff and work ethics. As a staff member, I knew the importance of
timely documentation but not just the documentation matters, right documentation
at right time for right person and action matters a lot.
This incident could stood out because the medication nurse was only wanted to
finish the task. According to the national co-coordinating council for medication
error, In health care professionals medication and documentation errors are very
common which need to be detected and documented for reporting them to
overcome the problem. The lack of time as well as a job done in a hurried manner
by the health care professional can also be one of the factors that led to the nurse
to do falsifying documentation. Moreover, work load and lack of organization as a
novice could be a contributing factor for such false documentation incidents as well.
The incident was observed during the morning which is particularly a busy part of
the day when everyone is around and busy in changing their shifts. With regards to
the case, the medication nurse wanted to finish the work as soon as possible
without regards to protocol and safety. She thought that by the time assigned
novice nurse would administered the medication, she could do the documentation
as well to save her time but the nurse haven't done. Self opinion regarding the case
was not biased, and reflection along with research provided that the in charge nurse
should have taken the rules and the regulations along with patient safety in to
account before working around the system and making documentation errors.
Other factors that can be contributing to the scenario involve many explanations.
The nurse could have been overburdened and busy or it is possible that the patient

got sick that is why she did not realize that she was doing false documentation.
Similarly may it is possible that the nurse simply was not aware of the possible
consequences of false documentation. the nurse could have been too risk oriented
and used to routine and mechanical tasks that she did not think about her role and
associated responsibilities. It is also possible that she had learned this practice from
other senior nurses through observation and role modeling that encouraged her to
just conduct documentation without medication administration. An addition factor
which leads toward this error is inadequate knowledge about the documentation
and its important. Denver hospital has reported a death of an infant just because
negligence of nursing practices by the allocated nurse in 1996.
The client health-care record is an important legal document. It provides information
that shows care has been provided, and it can be used to resolve questions or
concerns about accountability and the provision of care. Documentation provides a
chronological record of the many events involving a client from admission to
discharge and may be used to refresh the RN's memory. If they are required to give
evidence in court, a lawyer representing an RN will often rely on available
documentation to establish that the care provided by the RN was reasonable and
prudent. Similarly, a client's lawyer may use the same documentation to try and
show that the RN failed to meet the standard of a reasonable and prudent care
provider.
Learning attained from this episode pertains to the relevance and importance of
documentation. Documentation is considered of significant value to the registered
nurse in their daily professional work and as well as for increasing patient safety
along with the liability and safety of the staff as well. In addition explorations of the
potential causes for documentation were conducted to shed light on the incident.
Analyzing the situation, it was learnt that nursing practices must be evidence based
in order to be credible and reliable. It was realized that good documentation
practice can demonstrate professional responsibility and accountability which is the
key component in the nursing profession.

To conclude, it can be stated that care remains the essence, the unique and major
feature of healthcare professionals. Unhealthy and false documentation can put
patient and staff under risk with elevated safety issued. It is therefore
recommended that health care