Abstract
We manage most of medical slips by writing down information by hand, because our hospital does not have an ordering system. For instructions on cancer chemotherapy, we suggested that posting instructions of the medical card in the injection prescription by each medicine bottle could lead to the possibility of some medication errors on account of 1) a risk for posting errors and 2) difficulty of general inspection. To improve the present situation, we established a system called “Prescription-Instruction Sheet of Chemotherapy” and have utilized it since July, 2001. It is made up of triple carbon paper A 4 size which is printed on the whole protocol of chemotherapy. It shows three functions, namely a prescription, a copy of the ward and an instruction sheet for nurses, as soon as a doctor fills in the blanks on the sheet.One year after introducing this system, we investigated a questionnaire to ask about the usefulness of this sheet to the medical stuff. The results were highly satisfactory, because most opinions mentioned that the posting of medical cards become unnecessary and the schedule is easy to understand at first sight. Nurses had some recommendations to improve this sheet. On the other hand, the number of incidents and accident reports decreased after introducing this system to the department of nursing.We conclude that this system helped to improve the risk management owing to the establishment of this new system.
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