[Written documentation of drug prescriptions. Accordance between medical records and dispensing records].
A comparison of drug prescriptions entered on case records and nurses' drug lists is presented. Of 144 patients admitted to a general internal medicine ward, nine received no drugs. The remaining 135 had 606 (75.0%) items on both case record and drug list, 114 (14.1%) on the case record only, and 88 (10.9%) on the drug list only. For 48 patients (35.6%) drug lists were in accordance with their case record concerning the number and type of drug prescribed. Prescriptions on both documents were characterised by lack of accuracy. Of the 709 prescriptions on case records and 684 on drug lists, 428 (60.4%) and 411 (60.1%) respectively were unambiguous.


CONCLUSIONS
Drug prescribing based on transcription from case records to nurses' drug lists implies a considerable risk of discrepancies. Thus, there is a significant risk of incorrect drug administration. A standardised card for drug prescriptions for common use by both physicians and nurses will therefore now be taken into use.
Andersen
S E
SE
H:S Amager Hospital, medicinsk afdeling.
Fog
D
D
D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003718:Denmark; D011307:Drug Prescriptions; D005260:Female; D006748:Hospital Departments; D006801:Humans; D007388:Internal Medicine; D008297:Male; D008499:Medical Records; D008508:Medication Errors; D008875:Middle Aged; D009737:Nursing Records; D012042:Registries
Skriftlig dokumentation af medicinordinationer. Overensstemmelse imellem laegejournal og Medicinkardex.