shift is wild

Pharmacology · chapter 3 · Ethics, Legal Considerations, and Safety

Documentation and Informatics

The 14 things this section of the textbook says that you are most likely to be asked about — quoted word for word, not retold. Then 6 practice questions with the reasoning.

Skip to the questions ↓

Key points

  1. Latent versus active errors

    Errors that are a result of system failures and system design are called latent errors; in contrast, active errors are errors that are made by individual clinicians (Rodziewicz et al., 2023).

  2. Intentional risk-taking behavior

    An intentional risk-taking behavior could be a nurse who purposely chose not to identify a client prior to giving medication. They are knowledgeable about the institutional process but choose not to practice it.

  3. Blame-free reporting of errors

    The AHRQ encourages institutions to set up blame-free environments for individuals so they are able to report errors or near-misses without fear of punishment.

  4. Document at the time, not before

    Documentation should be accurate and timely, occurring near the time the provider made an observation or completed an intervention, such as medication administration. That said, it is important to document at the time or slightly after rather than before.

  5. The chart is a legal document

    It is crucial that all providers remember that the chart is a legal document that provides proof of the client’s status and the care that was delivered.

  6. Transitions of care raise error risk

    A transition of care includes the client’s admission to the hospital, transfer to another unit, and discharge home. Transitions of care are critical times that increase a client’s risk for medication errors.

  7. How medication reconciliation is done

    The nurse compares the list of medications the client is taking or is supposed to be taking with the list of newly ordered medications.

  8. Problems reconciliation can find

    Potential problems that may be identified include (1) the omission of a drug, (2) discrepancies between frequency or dosing, (3) duplicate drugs (this may happen when one provider orders a generic form of the drug and another provider orders by brand name), (4) contraindications, or (5) incorrect drugs.

  9. Carry a current medication list

    The nurse should instruct each client to carry a list of current medications with the dosage and frequency at all times.

  10. Documenting client teaching

    Each discipline should document any teaching that is performed, including when it occurred and who did the teaching. It should also include the topics discussed and the response to the education.

  11. Leading zeros and naked decimals

    Naked decimals (.4 mg or.1 mg) may result in medication errors because they can be interpreted as 4 or 1. Instead, write 0.4 mg or 0.1 mg.

  12. No trailing zeros in medication orders

    However, trailing zeros should never be used when writing medication orders or documenting dosages (Joint Commission, n.d.-a).

  13. Document medications in real time

    Documentation of medications administered or withheld should also be done in real time to protect client safety.

  14. Barcode scanning at the bedside

    Once the nurse scans the barcode on the client’s wrist, it identifies the client and opens the eMAR, which informs the nurse as to which medications should be administered.

Terms to know

Medication reconciliation
Medication reconciliation should be completed at any transition of care or outpatient visit, especially when more than one provider is orchestrating the care of the client.
Hard-stop alert
A hard-stop alert is one in which the user is not allowed to proceed without taking some kind of action.
Soft-stop alert
A soft-stop alert is one in which the alert is acknowledged, but the user may proceed.
Workaround
A workaround is a way of handling a problem or making something work without fixing the problem.
eMAR
The electronic medication administration record (eMAR) is a part of the EHR and serves as the official documentation for the medication administered or withheld by the nurse.
computerized prescriber order entry (CPOE)
Computerized Prescriber Order Entry (CPOE) An important aspect of the EHR is e-prescribing, also known as computerized prescriber order entry (CPOE).

Practice questions

Stuck on select-all-that-apply? How to take them one option at a time.

The graded version needs JavaScript. Every question is below anyway, with the answer and why.

Every question here, with the answer

  1. A nurse is reviewing a handwritten order that reads "morphine .4 mg IV." What is the safest action by the nurse?

    1. Give 4 mg, because the decimal point is probably a stray mark.
    2. Clarify the order with the prescriber, because a naked decimal can be misread.
    3. Give 0.4 mg, because that is what the prescriber most likely meant.
    4. Give 0.04 mg to stay on the safe side.

    Answer: Clarify the order with the prescriber, because a naked decimal can be misread.

    A dose written without a leading zero is a naked decimal and can be read as 4 instead of 0.4, which is a medication error. The nurse does not guess the intended dose; the order must be clarified and written as 0.4 mg.

  2. A client is being transferred from the intensive care unit to a medical floor. The receiving nurse compares the client's home medication list with the new transfer orders. What is the nurse doing?

    1. Computerized prescriber order entry
    2. Medication reconciliation
    3. A soft-stop override
    4. Barcode-assisted administration

    Answer: Medication reconciliation

    Comparing the list of medications the client takes with the newly ordered medications at a transition of care is medication reconciliation. CPOE is how prescribers enter orders, soft-stop alerts are acknowledged warnings, and barcode scanning verifies a drug at the bedside.

  3. During medication reconciliation at admission, which problems should the nurse look for? Select all that apply.

    1. A drug that is contraindicated for the client
    2. A different dosing frequency between the two lists
    3. The same drug ordered once by generic name and once by brand name
    4. The brand of the client's home glucose meter
    5. A home drug that was left off the new orders

    Answer: A drug that is contraindicated for the client, A different dosing frequency between the two lists, The same drug ordered once by generic name and once by brand name, A home drug that was left off the new orders

    Reconciliation looks for omissions, frequency or dosing discrepancies, duplicate drugs (for example generic and brand name orders), contraindications, and incorrect drugs. The brand of a glucose meter is not a medication discrepancy.

  4. The barcode scanner will not read a client's wristband. The medication is due now. Which action places the client at risk?

    1. Reporting the broken scanner so the problem is fixed.
    2. Checking the client's identity before giving the medication.
    3. Asking for a new wristband before giving the medication.
    4. Typing the client's name and medical record number into the system to document the dose manually.

    Answer: Typing the client's name and medical record number into the system to document the dose manually.

    Typing in the client's details to get around the scanner is a workaround: the drug is given but the problem is not fixed, and safety measures in the system are bypassed. The other actions solve the problem or keep identification in place.

  5. A nurse is documenting discharge teaching about a new medication. What should the documentation include? Select all that apply.

    1. The nurse's personal opinion of the client
    2. When the teaching occurred
    3. The topics discussed
    4. The client's response to the education
    5. Who did the teaching

    Answer: When the teaching occurred, The topics discussed, The client's response to the education, Who did the teaching

    Teaching documentation includes when it occurred, who did it, the topics discussed and the client's response, including whether the client could teach back the information. A personal opinion of the client is not part of it.

  6. At the end of a busy shift, a nurse wants to chart a scheduled 2200 medication at 1900 so it is done before report. What is the nurse's best action?

    1. Chart it now and give it at 2200.
    2. Chart it at the time of administration or slightly after.
    3. Ask the oncoming nurse to chart it at 1900.
    4. Chart it now and add a late note if it is not given.

    Answer: Chart it at the time of administration or slightly after.

    Documentation should occur at the time of the intervention or slightly after, never before, because the chart is a legal document that proves the care delivered. Charting a dose before it is given records care that has not happened.

Where every quote comes from

Section 3.3 Documentation and Informatics of Pharmacology for Nurses by Tina Barbour-Taylor, Leah Mueller (Sabato), Donna Paris, Dorie Weaver, OpenStax, 2024. Read the whole section free at openstax.org.

The textbook is licensed under CC BY-NC-SA 4.0. This page quotes it word for word and adds the headings, the order and the practice questions; references to the book's figures and stray spaces left by its formatting are removed. The page is shared under the same licence. Nothing here is sold.