Mistaken Identity ( Safety / Record Keeping / Context in practice )
You are a newly qualified nurse, working on a paediatric unit. You are receiving handover from an experienced nurse, Julie, who has just completed a 12 hour shift, the third in a row, due to staff shortages. Julie complains to you through handover that she has been feeling unwell during the latter end of her shift and that she thinks she is developing a possible upper respiratory infection. She also says ' these long days are killing me ' and that she 'cant wait to go back to her 8 hour shift pattern after her days off.'
During handover she reports on a child who has had a catheter inserted, following an episode of acute retention of urine, following abdominal surgery the same day. The patients name is Mark Smith. She gives a brief handover, as she is keen to leave the unit, and conveys that the rest of his information can be found in his notes where she has made a comprehensive entry of assessment, interventions and evaluations.
You are assigned to care for Mark during your shift and immediately consult his notes in order to decide how best to proceed with his care for the shift where he is entrusted to you. However, you soon realise that there appears to be no entry made by Julie. You are confused and suddenly realise that there are 2 patients on the ward with similar names : Mark Smith and Marcus Smith. You decide to check Marcus Smith's notes and you see that indeed a comprehensive entry has been made by Julie. It is now clear that Julie has written in the wrong notes by mistake.
It is proposed that in the interests of safety you report this mistake to Julie's line manager