High Incidence of Medication Documentation Errors in a Swiss University Hospital
Author Information
Author(s): Hartel Maximilian J, Staub Lukas P, Röder Christoph, Eggli Stefan
Primary Institution: Bern University Hospital, Inselspital
Hypothesis
The study aimed to identify and quantify errors in the handwritten drug ordering and dispensing documentation processes.
Conclusion
The study revealed a high incidence of documentation errors in the traditional handwritten prescription process, with most errors occurring during transcription.
Supporting Evidence
- Documentation errors occurred in 65 of 1,934 prescribed agents (3.5%).
- The incidence of patient charts showing at least one error was 43%.
- Prescribing errors were found 39 times (37%), transcription errors 56 times (53%), and administration documentation errors 10 times (10%).
- The handwriting readability was rated as good in 2%, moderate in 42%, bad in 52%, and unreadable in 4%.
Takeaway
Doctors writing by hand can make a lot of mistakes when giving medicine to patients, and using computers might help fix that.
Methodology
The study analyzed 1,934 ordered agents from 165 patients for medication documentation errors, categorizing them into prescribing, transcription, and administration documentation errors.
Potential Biases
The observational nature of the study may introduce bias in the documentation process.
Limitations
The study was retrospective and conducted in a single institution, limiting the generalizability of the findings.
Participant Demographics
The median patient age was 55 years, with 42% female participants.
Statistical Information
P-Value
p<0.0001
Confidence Interval
95% CI 0.38-0.50
Statistical Significance
p<0.0001
Digital Object Identifier (DOI)
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