Background: Medication errors have been reported to be a leading cause of death in hospitalized patients. In this study we focused on identifying and quantifying errors in the handwritten drug ordering and dispensing documentation processes which could possibly lead to adverse drug events.
Methods: We studied 1,934 ordered agents (165 consecutive patients) retrospectively for medication documentation errors. Errors were categorized into: Prescribing errors, transcription errors and administration documentation errors on the nurses' medication lists. The legibility of prescriptions was analyzed to explore its possible influence on the error rate in the documentation process.
Results: Documentation errors occurred in 65 of 1,934 prescribed agents (3.5%). The incidence of patient charts showing at least one error was 43%. Prescribing errors were found 39 times (37%), transcription errors 56 times (53%), and administration documentation errors 10 times (10%). The handwriting readability was rated as good in 2%, moderate in 42%, bad in 52%, and unreadable in 4%.
Conclusions: This study revealed a high incidence of documentation errors in the traditional handwritten prescription process. Most errors occurred when prescriptions were transcribed into the patients' chart. The readability of the handwritten prescriptions was generally bad. Replacing the traditional handwritten documentation process with information technology could potentially improve the safety in the medication process.