Posted 28th May 2012 in Medication Safety

Prescription errors can and do lead to patient harm. Changes in care, particularly on admission to hospital, are times when medication errors are most likely to occur.

This study looks at the number and type of prescription errors made by clinicians within the first 24 hours of a general medical patient’s hospital admission. The study took place in April 2010 and involved four hospitals across New Zealand and Australia. Each hospital aimed to audit the medicine charts of 200 consecutive adult patients and record the following errors:

  • drug not prescribed by generic name
  • drug name illegible
  • prescription not signed by prescriber
  • prescribers name not provided or illegible
  • prescription undated
  • inadequate documentation of allergy.

The final analysis looked at a total of 7,497 prescriptions written for 715 patients with an average age of 66.7 years.  There were 6,403 drugs prescribed which equated to an average of nine drugs per patient.

The results revealed that simple prescribing errors were prevalent, with medicine charts for 672 out of the 715 patients containing at least one error. The research found that the more drugs a patient was prescribed, the greater the likelihood of an error being made.

The medication charts of over half of all patients included a drug prescribed by its trade name and just over 6% of patients had charts containing an illegible drug name, leading to an increased risk of duplication. Prescriptions were not signed on the charts of a fifth of patients and not dated on the charts of over a third of patients. The frequency of these error types differed significantly between the sites suggesting possible variances in chart design, culture or education. Nearly one quarter of all patients had charts which contained inadequate documentation around allergies creating a risk of contraindicated drugs being prescribed.  Where the chart had been reviewed by a pharmacist, the allergy documentation was more likely to be complete.

The authors found that their results were similar to other studies in this area. They noted that prescribing was a complex process of which only limited elements had been examined. They concluded that future improvements should focus on multidisciplinary collaboration and competency based training.

The full report is accessible here.

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