During interdisciplinary rounds, a critical situation can arise when a documented assessment contradicts the patient’s actual condition. This scenario highlights the importance of clear communication and adherence to ethical principles in nursing practice.

Identifying the Discrepancy:

We, the interdisciplinary team, are presented with a discrepancy. The physician has documented that the patient is alert and oriented x3 (AOx3), indicating awareness of person, place, and time. However, during rounds, it’s clear the patient exhibits confusion, which the physician acknowledges. This inconsistency raises concerns about patient safety and accurate documentation.

Applying Ethical Principles:

The principle of advocacy from the “Dynamics of Nursing: Art and Science of Professional Practice” compels us to act. Nurses have a fundamental ethical obligation to advocate for their patients’ well-being. In this case, ensuring an accurate assessment is paramount.

Addressing the Discrepancy with Advocacy:

Here’s how I would approach this scenario:

1. Privately Discuss with the Physician: I would politely approach the physician after rounds and express my concern about the documented AOx3 conflicting with the patient’s current state.
2. Collaboratively Reassess: I would propose a collaborative reassessment of the patient’s mental status, involving both the physician and myself. This reassessment would ensure a complete and accurate picture of the patient’s condition.
3. Document Discrepancy: If the reassessment confirms confusion, I would document both the initial AOx3 documentation and the current assessment findings. This creates a clear record of the discrepancy and the steps taken to address it.

Importance of Organizational Culture:

A supportive organizational culture is crucial for managing errors effectively. Here are ways such a culture can help:

• Open Communication: A culture that encourages open communication allows nurses to voice concerns without fear of repercussions.
• Just Culture: A just culture focuses on identifying and preventing systemic errors rather than solely blaming individuals. This fosters a learning environment where errors can be reported and addressed constructively.
• Teamwork: A strong team environment fosters collaboration and information-sharing, helping to catch discrepancies before they reach the patient record.

Conclusion:

By applying the principle of advocacy and leveraging a supportive organizational culture, we can address discrepancies in patient assessments, ensuring patient safety and accurate documentation. Open communication and collaboration are essential in maintaining patient well-being and fostering a culture of continuous improvement in healthcare delivery.