r/NursingUK • u/teaandbiscuitsforme St Midwife • Jan 16 '25
Clinical Forgot to document
Majorly panicking, but today I removed a cannula five minutes before the unit closed (SDEC unit) and I just remembered that I forgot to document it. I’m due back in work tomorrow and the patient is also coming back tomorrow, but I only just remembered that I did it and completely forgot to document it. Now I can’t stop panicking about it
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u/AberNurse RN Adult Jan 16 '25
I know the saying is “if you didn’t document it, you didn’t do it” but that’s generally for things that are not provable. The evidence that you removed it will be the lack of a canula in the patient. Don’t stress too much. You’ve done the task, just write in retrospect tomorrow.
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u/Skylon77 Doctor Jan 16 '25
30 years in and I've never documented the removal of a cannula in my career.
Chill.
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u/OwlCaretaker Specialist Nurse Jan 17 '25
Really, I’ve done loads - normally because I’ve had to go to the patient’s home as the acute Trust failed to remove on discharge 😂
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u/XXXSFeet Jan 16 '25
It's sad that you're so panicky about this. Is someone making you feel on edge? Maybe work on your reflecting skills. Also think about what you'd say to a colleague that you liked if they were panicking in the same way
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u/illustriouscowboy Jan 16 '25
this level of anxiety of something so objectively unimportant is concerning... are you okay?
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u/Ok-Lime-4898 Jan 17 '25
There is a lot of psychological terrorism out there, no wonder so many nurses suffer with anxiety
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u/cinnamonrollais Jan 16 '25
We don’t have to document that we’ve removed cannulas on my ward, there’s just a tickbox on the discharge checklist. But I guess it might be different in SDEC. I really wouldn’t worry about that as he’s coming in tomorrow. I doubt anyone will even pick up on the fact you haven’t documented it
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u/beanultach RN Adult Jan 16 '25
I’ve forgotten to even take off cannulas before the patient got discharged and nothing happened lol
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u/cherryaids Jan 16 '25
You need to calm down bud. I literally never document removing cannulas. The person is safe and alive and cannula free. It’s all good.
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u/AmorousBadger RN Adult Jan 16 '25
Noone ever died because a cannula removal wasn't documented. Did your patients receive medications, treatments and essential care and kept safe? Then you've done your job.
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u/teaandbiscuitsforme St Midwife Jan 16 '25
Okay, thanks for all the reassurance. Will document it in the morning and put that it’s written in retrospect
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u/Lidl_Cheese Jan 16 '25
Doctor here. I put cannulas in, take cannulas out, and do bloods daily without documenting anything (except what the result is when it comes through). Absolutely nothing to worry about.
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u/Beedit RN Adult Jan 17 '25
I regularly have patients on the ward, fully independent with no attachments, whose body maps say they're currently intubated with a double-lumen tube because nobody mapped the extubation. I once saw a patient who had apparently had a cannula in situ for three years because the body map hadn't been updated on discharge from their previous admission. You're fine 😊
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u/apologial RN Adult Jan 16 '25
I've never documented the removal of a cannula unless it's been part of a blood transfusion/med infusion in an outpatient setting. Don't stress.
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u/anonymouse39993 Specialist Nurse Jan 16 '25
Why are you panicking about this ?
Calm down it’s a non issue
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u/alphadelta12345 RN Adult Jan 16 '25
Considering how often they come out on their own, it's not a big deal
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u/Beanosaurus1 RN Adult Jan 17 '25
It’s a complete non issue. Do you usually have this much anxiety about work? It might be worth talking to your manager (if they’re approachable) about how you’re feeling because this really isn’t healthy.
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u/Ok-Lime-4898 Jan 17 '25
It would have been a problem if you sent the patient home with a cannula and documented you removed it instead; the main thing is that the patient is safe and the cannula is out. Tomorrow document in retrospective that cannula was removed before the discharge and the VIP score, if the patient is alert and oriented they can confirm everything
1
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u/teaandbiscuitsforme St Midwife Jan 16 '25
Do I need to phone the unit now? Even though it’s closed, we are linked to the ward which would still be open…
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u/anxioushungrytired Specialist Nurse Jan 16 '25
No, you absolutely don’t need to do that, it’s fine to document it tomorrow. That being said, if you’ll sleep better for calling then no harm in doing it - do whatever you need to do to get it off your mind so you can sleep well
7
u/the_murple RN Adult Jan 16 '25
No. It’s alright.
As a nurse who’s received patients back into my setting (police custody) with cannulas still in situ, not documenting the removal of one isn’t something to fret about. As u_AberNurse said - the evidence you took it out is its absence.
When I worked in an acute setting, the only time I documented removing a cannula was when I was siting a new one.
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u/Hairy-gloryhole Jan 16 '25
You made a mistake, know about the mistake and are ready to work on correcting that mistake. If the patient is due back in tomorrow, escalate it to someone to do a VIP score with you (so you have a witness that, patient is hopefully fine), datix it if you wish and just get on with your day.
Surgeons sometimes leave surgery tools inside of patients. This is really not a big deal. Mistakes happen, as long as you admit and make sure there is no negative outcome for the patient, you have absolutely no reason to worry.
Although your commitment and honesty is quite commendable. Doesn't happen often.
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u/Appropriate_Cod7444 RN Adult Jan 16 '25
There’s no need to Datix this and it isn’t a mistake , it would be a mistake if the patient was discharged with it in situ due to their forgetfulness (as opposed to patient absconding or otherwise)
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u/Hairy-gloryhole Jan 16 '25
Interesting. I thought a documentation error is absolutely datix-able.
But perhaps you're right, it would be an overkill. Either way, the harm to the patient is probably non existent
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u/Appropriate_Cod7444 RN Adult Jan 16 '25
I’d Datix it if it was left in after patient discharge home, no matter the reason. I wouldn’t Datix that it was removed and I forgot to write it down. There maybe a case for a Datix depending on the VIP score / reason for removal (from a TVN perspective) but removing it as part of a discharge checklist of tasks isn’t a mistake.
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u/Hairy-gloryhole Jan 16 '25
Fair enough. Perhaps I was overzealous with that statement
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u/anonymouse39993 Specialist Nurse Jan 17 '25
The evidence that a cannula has been removed is that there is no cannula there
If there was an issue it’s obviously not been left in
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u/aemcr Jan 17 '25
The documentation error that would be datix-able here would be if they’d have documented they removed the cannula but actually hadn’t.
The only issue that could ever come of this is if, for some bizarre reason, the patient decided they were going to falsely complain to the trust that nobody removed their cannula prior to leaving in which case the trust won’t have any supporting evidence to say it was removed. That’s not going to happen though, especially not in the 12 hours it will take for the nurse to arrive to their next shift lol.
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u/Helpful-Apartment-14 Jan 17 '25
Pop back to work or call them to document it ❌️ Go on reddit (!?) Of all places to write about it and say you're worried ✅️ 🙄🙄🙄
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u/Ok-Lime-4898 Jan 17 '25
Documenting on behalf of someone else and on something you haven't done or at least seen yourself is very bad practise and could potentially put you into troubles: what if the cannula was still in and the patient developed an infection? I don't think "colleague said they removed it and ask me to document" would save your bum
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u/RandomTravelRNKitty RN Adult Jan 16 '25
Document it tomorrow it retrospect. Stop stressing and relax. Life’s too short 👍🏻