Abstract

Background: Prescribing errors are quite common and according to one estimate out of 100 patients admitted into UK hospitals 15 will have some form of prescribing error in their records. It is a general understanding that most of the time these errors are made due to lack of awareness. Severity of these errors can range from minor to major mistakes that can lead to fatal results. Materials and Methods: A simplified anonymous approach of identifying these errors and then using a step wise approach to educate the prescribers’ especially junior doctors can be quite fruitful in reducing these errors. Unfortunately there are not many studies or projects available to back our proposal however these seems a logical way forward and is exactly what we have shown in our study. Results: We performed a prospective snapshot study involving 100 inpatients to get baseline measurements. The errors and mistakes were identified and fed back to the junior doctors in an anonymous manner. Clear & legible writing, frequency of use, responsible consultant name, allergy box filled, VTE assessment, oxygen prescribing and labeling of medication discontinuation were the most common negligence identified. At the same time junior doctors were reminded of local prescription standards and guidelines which usually don’t form part of induction. Conclusion: Multiple deficient areas were identified during this audit like legible writing, dosage frequency, VTE prophylaxis and oxygen prescription. It was highlighted to junior doctors how important are these components as they play a key role in patient getting better after medical review. Above mentioned steps did improve prescription errors to an extent, but aim should be to achieve 100% results.  Repeated reminders are important in this case as that helps to improve practice and avoid clinical accidents.

Highlights

  • Medication error is a flaw in the process of formulating, dispensing, managing, prescribing, monitoring or providing advice on medicines [1]

  • Multiple deficient areas were identified during this audit like legible writing, dosage frequency, Venous thrombo-embolism (VTE) prophylaxis and oxygen prescription

  • It was highlighted to junior doctors how important are these components as they play a key role in patient getting better after medical review

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Summary

Introduction

Medication error is a flaw in the process of formulating, dispensing, managing, prescribing, monitoring or providing advice on medicines [1]. These errors can increase patient morbidity, mortality and in turn can lead to prolonged hospital stay with its financial complications. It is a general understanding that most of the time these errors are made due to lack of awareness Severity of these errors can range from minor to major mistakes that can lead to fatal results. Clear & legible writing, frequency of use, responsible consultant name, allergy box filled, VTE assessment, oxygen prescribing and labeling of medication discontinuation were the most common negligence identified.

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