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709 ‘What can go wrong?’ Analysis of slips and errors in documentation of drugs in a tertiary paediatric unit, Sri Lanka
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709 ‘What can go wrong?’ Analysis of slips and errors in documentation of drugs in a tertiary paediatric unit, Sri Lanka
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709 ‘What can go wrong?’ Analysis of slips and errors in documentation of drugs in a tertiary paediatric unit, Sri Lanka
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Journal Article
709 ‘What can go wrong?’ Analysis of slips and errors in documentation of drugs in a tertiary paediatric unit, Sri Lanka
2023
Overview
Drug prescription by a medical officer till delivery of medications by a nursing officer possesses many avenues for mistakes. Medications are copied to the drug chart by nursing officers. The fact that paediatric medications are dispensed in specific dosages for different children according to the body weight increases the error margin further.Our audit aimed to analyze the degree of adherence of documentation of medications in the drug chart to the standard protocols.MethodsA retrospective study was done over one month at the Professorial Paediatric Unit, Colombo South Teaching Hospital, Srilanka. A data collection form based on WHO standards (Guide to good prescribing) was used. The following components were assessed in 200 drug charts: Patient (name, age, bed head ticket number, weight), General (date, legibility, documentation of allergies, signature of the prescriber) and Drug (generic name, route, dose, frequency, abbreviations).Results923 drugs were prescribed in 200 Bed Head Tickets(BHT) with the mean number of approximately 5 drugs per BHT. 88.5% of prescriptions contained at least one error. Patients’ details were mentioned virtually in all BHTs, except the weight of the patient – 17% of prescriptions did not contain. Date was not mentioned only in 4 (2%) drug charts and legible hand writing reached the high standards(98.5%). Allergies were documented in 3.5% of drug charts, yet questioning the certainty of non-allergies as they were not documented.Out of 923 drugs, paracetamol and antibiotics were prescribed mostly, accounting 17% each, followed by bronchodilators (14%). Spelling mistakes were noted in 15.6% of the total prescribed drugs with antibiotics (40.2%) and antihistamines (20.8%) having the highest errors. Usage of abbreviations was noted in 15% of total drugs prescribed and bronchodilators (61.9%) contributed to the highest. Trade names were used in 8.3% of prescriptions, especially in prescribing vitamins and probiotics. Route, dose and frequency were documented and contributed to 56.5%, 72% and 89.5% respectively. Incorrect dose (2.9%) and frequency (1%) were minimally noted. None contained the prescriber’s signature.ConclusionDeficiencies were identified in adhering to the standards of documentation in all areas which could lead to disastrous as well as legal issues. Documentation standards to be incorporated into medical and nursing curricula. It is vital to disseminate the results among doctors as well as nurses and to carry out regular
