‘If you didn't chart it, you didn't do it’: a retrospective chart review of errors omission in endoscopy care

Abstract

Background: Patients put themselves in the care of a competent healthcare team. Missed nursing care is a universal phenomemon, and endoscopy is no exception. Although endoscopic procedures for the diagnosis and treatment of gastrointestinal diseases are usually minimally invasive, highest standards of nursing care and documentation are to be ensured for patient safety. Aim: This study aimed to identify and quantify the type and frequency of nursing care that was documented. Methods: A descriptive retrospective chart review was conducted after formal approval and ethics clearance at a tertiary hospital. Documentation on the nurses' records (n=717) for the period January to December 2019 that met the sampling criteria were audited for a full range of nursing care activities during endoscopy. Data was extracted using a validated (CVI 0.87-1), reliable (Kappa 0.83; ICC 0.98) data abstraction form. Data were analysed using descriptive statistics. Results: Of 47 care activities in each of 717 records, 41.5% were undocumented. More care went undocumented in the intra-procedure (56.1%) and post-procedure (54.2%) periods than the pre-procedure period (15.4%). The proportion of each activity going undocumented ranged widely from 0% to 100%. Conclusion: The findings demonstrate that many aspects of care related to endoscopy were not documented and thus likely omitted. Proper care and documentation can help identify and mitigate any harm to patients.