Documentation errors in paediatric drug charts: an Audit

INTRODUCTION:

Documentation errors leading to medication errors pose a health risk to hospitalised patents. Maintenance of the drug chart in hospitalized patients is done by nursing staff in Sri Lanka. This audit was carried out in a paediatric unit to assess documentation errors and nature of risk to patients.

 

METHOD:

Drug charts of 236 Bed Head Tickets (BHT) were analyzed over a period of one month in a single paediatric unit. Parameters of concern were generic and propriety names of drugs, spelling mistakes, abbreviations and legibility of handwriting.

 

RESULTS:

Total of 882 drugs were written in 236 BHTs. The mean number of drugs per one BHT was 3.7. At least one error was observed in 473 (53.6%) names of drugs. 25% (225) of drug documentations had spelling mistakes. In majority of cases with spelling mistakes, there was an error in one letter (88.8%). Abbreviations, propriety names and illeg­ible hand writing were written in 134 (15.1%), 104 (11.7%) and 18 (2%) occasions respectively. Paracetamol was the most commonly documented drug and 30% of the time it was written in abbreviations. Most frequent spelling mistakes were seen in Clarithromycin (95%) and Amoxicillin (74%). Usage of trade name was commonly seen when writing Chlorpheniramine (26.5%). The least number of spelling mistakes were seen in salbutamol (3%).

 

CONCLUSION:

There was no standard practice of maintaining drug charts in hospitalized patients and it may pose a significant health risk. Authors would like to suggest doctors to take the responsibility of the maintenance of drug charts in order to minimize this high prevalence of documentation errors.