High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process

Maximilian J Hartel1*, Lukas P Staub2, Christoph Rder1,2 and Stefan Eggli1 Research Group for e-medication, Bern University Hospital, Inselspital, CH-3010 Berne, Switzerland
2

Maurice E. Mller Research Centre, Institute for Evaluative Research, University of Berne,

Background

Stauffacherstrasse 78, CH-3014 Berne, Switzerland

Medication errors have been reported to be a leading cause of death in hospitalized patients. In this study we focused on identifying and quantifying errors in the handwritten drug ordering and dispensing documentation processes which could possibly lead to adverse drug events.

Methods
We studied 1,934 ordered agents (165 consecutive patients) retrospectively for medication documentation errors. Errors were categorized into: Prescribing errors, transcription errors and administration documentation errors on the nurses' medication lists. The legibility of prescriptions was analyzed to explore its possible influence on the error rate in the documentation process.

Results
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%.

Conclusions
This study revealed a high incidence of documentation errors in the traditional handwritten prescription process. Most errors occurred when prescriptions were transcribed into the patients' chart. The readability of the handwritten prescriptions was generally bad. Replacing the traditional handwritten documentation process with information technology could potentially improve the safety in the medication process.

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Policies, procedures, and protocols

Lack of appropriate policies, procedures, and protocols can impact medication safety, as seen in a few small studies. In a study of malpractice cases, medication errors were associated with lack of administration protocols and ineffective nurse supervision in delegating administration. 80 However, even when policies are in place, they may not necessarily improve safety. For example, a review of two studies in the literature found that medication errors did not necessarily decrease with two nurses administering medications (e.g., double-checking).30 In addition, appropriate policies may not be followed. Doublechecking policies are commonly used as a strategy to ensure medication safety. When errors occurred under such policies, failure to double-check doses by both pediatric and adult nurses 58 and nurses in a Veterans Affairs (VA) hospital102 were reported. However, research presented in two literature reviews

offers somewhat conflicting information. In the first review of three studies, following double-checking policies did not necessarily prevent errors.39 Yet in the other review, failure to adhere to policies and procedures was associated with errors.30

Documentation of the medication administration process

One small study investigated nurse adherence to a hospital policy to document medications administered and their effects on patients. From a sample of 12 nurses in one hospital, one-third of progress notes were found to contain information about administered medications, yet only 30 percent of those progress notes included medication name, dose, and time of administration, and only 10 percent documented information about desired or adverse effects of medications. Medication education, outcomes of administered medication, and assessment prior to administering were not documented in any progress note. Only half of withheld medications were documented.105 In a review of records to detect medication errors, Grasso and colleagues43 found that 62 percent did not document doses as administered.

Documentation of medication management by graduate nurses in patient progress notes: a way forward for patient safety.
Aitken R, Manias E, Dunning T. Source
School of Nursing, The University of Melbourne, Victoria.

Abstract
Nursing documentation provides evidence of nurses' management, the patient response, and evaluation of care. The aim of the study was to examine how graduate nurses document their medication management in the progress notes. A prospective clinical audit of patient medication charts and the progress notes made by 12 graduate nurses was undertaken. Graduate nurses were also individually interviewed and asked clarifying questions about their medication management. Documentation was examined based on four areas: assessment, planning care, administration of medications, and evaluating outcomes of medications. Recorded information about assessment focused on cues of a biomedical rather than a psychosocial nature. Planning care involved non-specific documentation of discharge planning needs, and little information about communication with doctors, pharmacists, nurses, patients and next of kin. Administration of medications included details about the names of medications given to patients, but no information about medication education provided to patients during this time. Evaluation of outcomes of medication administration was poorly documented. Graduate nurses tended to focus on assessing medications before their administration without considering how the patient responded to treatment. Recommendations are proposed for improving the quality of graduate nurses' progress notes. These recommendations include implementing and evaluating protocols that link nurses' decision-making to documentation processes. Adopting a supportive multidisciplinary approach to quality improvement and providing education that emphasises written documentation of verbal communication are also recommended.

Medication Errors Associated with Documented Allergies

Pa Patient Saf Advis 2008 Sep;5(3):75-80. Pennsylvania

ABSTRACT
The selection of appropriate medications and dosages is dependent upon the availability and review of critical patient information. Without patient-specific clinical information, such as age, weight, allergies, diagnosis, and laboratory values, healthcare practitioners cannot develop safe and effective treatment plans. As many as 18% of serious, preventable adverse drug events stem from practitioners having insufficient information about the patient before prescribing, dispensing, and administering medications. Review of data from PA-PSRS reveals more than 3,800 reports of cases in which patients received medications to which they had documented allergies. Narcotics and antibiotics were the most common medications listed in reports. Types of breakdowns in the communication of allergy information include documentation of patients allergies on paper but not entered into the organizations compute rized order-entry systems, allergy information not consistently documented in expected locations, organizations attempts to list every drug allergen on the wristband, and allergies arising during episodes of care but not documented in the medical record or communicated to appropriate staff. Strategies to address problems with patients documented allergies include adding clear and visible prompts in consistent and prominent locations; listing patient allergies, as well as a description of the reaction to the allergen, on all admission order forms; eliminating the practice of writing drug allergens on allergy arm bracelets; and making the allergy reaction selection a mandatory entry in the organizations order-entry systems.