Unsafe nursing documentation: A qualitative content analysis

Abstract

Background:Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics.Objectives:To explore factors influencing nursing documentation from nurses’ perspectives in the Iranian nursing context.Methods:This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients’ medical files were used for data collection.Ethical considerations:This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent.Findings:The main theme of this study was “unsafe documentation.” Two categories, “types of errors in reporting” and “reasons of errors in reporting,” and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context.Conclusion:In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice.

Disclosing and Reporting Practice Errors by Nurses in Residential Long-Term Care Settings: A Systematic Review

“…Workplace characteristics, in terms of the presence of a positive and supportive atmosphere for reporting and disclosing practice errors, were highlighted as affecting reporting. Improvement in patient safety requires incident reporting by all healthcare staff [63] and depends on support and encouragement [12], appropriate work conditions, supervision, teamwork, and collaboration [64][65][66]. Reducing nurses' concerns regarding reprimands and punishment after reporting practice errors appears to improve error disclosure and reporting [67].…”

Causes of maternal deaths and delays in care: comparison between routine maternal death surveillance and response system and an obstetrician expert panel in Tanzania

“…Medical files are widely used to determine underlying causes of facility maternal deaths. In view of poor documentation of medical files in health facilities [13][14][15] or in instances when medical records are not available, such as death at home verbal autopsy (VA), is increasingly viewed as an alternative method of standardised interviews with bereaved families [16][17][18]. Using multiple sources may provide a more complete understanding of the circumstances of death and its causes.…”

Cuidados de enfermagem omissos num contexto hospitalar português: perceção dos enfermeiros sobre estratégias minimizadoras

“…As the object of an audit or process of continuity of care, the documentation of nursing care is a relevant aspect that reflects ethical and safe nursing care. As the records are one of the nurses' responsibilities, they must be accurate and clear and follow the legal, ethical, and professional structure (Ahmandi et al, 2019). Therefore, the following suggestions were made to the documentation standard used in the institution: need to redesign the record-keeping software, facilitate processes, and condense the several sector systems since the use of these systems can generate stress in nurses with difficulties in using information technologies (Ahmandi et al, 2019).…”