Impact of a standard medication chart on prescribing errors: A before-and-after audit

Quality and Safety in Health Care

Volumn 18, Issue 6, 2009, Pages 478-485

  Coombes, Ian D ^a,b   Stowasser, D A ^a,b   Reid, C ^a   Mitchell, C A ^a,b  

^a ROYAL BRISBANE AND WOMEN'S HOSPITAL   (Australia)

^b UNIVERSITY OF QUEENSLAND   (Australia)

Author keywords

[No Author keywords available]

Indexed keywords

WARFARIN;

ARTICLE; AUSTRALIA; CLINICAL PRACTICE; DRUG SAFETY; HUMAN; INTERNATIONAL NORMALIZED RATIO; MAJOR CLINICAL STUDY; MEDICAL AUDIT; MEDICAL DOCUMENTATION; MEDICAL RECORD REVIEW; MEDICATION ERROR; NURSE; OBSERVATIONAL STUDY; PHARMACIST; PRESCRIPTION; RISK REDUCTION; STANDARDIZATION;

AUSTRALIA; CLINICAL AUDIT; FORMS AND RECORDS CONTROL; HOSPITALIZATION; HUMANS; MEDICAL AUDIT; MEDICAL RECORDS; MEDICATION ERRORS; NATIONAL HEALTH PROGRAMS; PROCESS ASSESSMENT (HEALTH CARE); QUALITY ASSURANCE, HEALTH CARE;

EID: 73349130749     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2007.025296     Document Type: Article

References (42)

1. Aronson JK. Balanced prescribing. Br J Clin Pharmacol 2006;62:629-32.
2. Stowasser D, Allinson Y, O'Leary K. Understanding the medicines management pathway. J Pharm Pract Res 2004;34:293-6.
3. Bates D, Boyle D, Vander Villet M, et al. Relationship between Medication Errors and Adverse Drug Events. J Gen Intern Med 1995;10:199-205.
4. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA 1995;274:29-34.
5. Dean B, Barber N. What is a prescribing error? Qual Health Care 2000;9:232-7.
6. Australian Commission on Safety and Quality in Health Care. Definitions of safety and quality in health care. http://www. safetyandquality.org/internet/safety/ publishing.nsf/Content/former-pubs- archive-definitions (accessed 04 Sept 2007) (last updated: 28 Aug 2006).
7. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results from the Harvard malpractice study II. N Engl J Med 1991;324:377-84.
8. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian health care study. Med J Aust 1995;163:458-71.
9. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med 2001;94:322- 30.
10. Lesar TS, Lomaestro BM, Pohl H. Medication prescribing errors in a teaching hospital: a 9-year experience. Arch Intern Med 1997;157:1569-76.
11. Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients-excess length of stay, extra costs, and attributable mortality. JAMA 1997;277:301-6.
12. Dean Franklin B, Vincent C, Schachter M, et al. The incidence of prescribing errors in hospital in patients: An overview of the research methods. Drug Saf 2005;28:891-900.
13. Dean B, Schachter M, Vincent C. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet 2002;359:1373-8.
14. Barber N, Rawlins M, Dean Franklin B. Reducing prescribing error: competence, control, and culture. Qual Saf Health Care 2003;12:i29-32.
15. Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA 1995;274:35-43.
16. Winslow EH, Nestor VA, Davidoff SK, et al. Legibility and completeness of physicians' handwritten medication orders. Heart Lung: J Acute Crit Care 1997;26:158-64.
17. Coombes I, Stowasser D, Coombes J, et al. Why do interns make prescribing errors?-A qualitative study. Med J Aust 2008;188:89-94.
18. Aronson JK. A prescription for better prescribing. Br J Clin Pharmacol 2006;61:487-91.
19. Wu A, Folkman S, McPhee S, et al. Do house officers learn from their mistakes ? JAMA 1991;265:2089-94.
20. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA 1997;277:312-7.
21. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003;348:2526-34.
22. Franklin BD, O'Grady K, Donyai P, et al. The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study. Qual Saf Health Care 2007;16:279-84.
23. Koppel R, Metlay J, Cohen A, et al. Role of Computerised Physician Order Entry Systems in Facilitating Medication Errors. JAMA 2005;293:1197-203.
24. Coombes I, Stowasser D, Mitchell C, et al. Effect of computerised prescribing on use of antibiotics. Med J Aust 2004;180:140-1.
25. Walton A, Harris S, Chaput de Saintonge D, et al. The New Royal London Hospital prescription sheet. Hosp Pharm Pract 1992:321-326.
26. Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: a randomised controlled trial. Pediatrics 2005;116:1299-302.
27. Australian Council for Safety and Quality in Health Care. Health reform-safety and quality action areas. http://www.health.gov.au/ internet/safety/publishing.nsf/ content/E2115B84DFEEAD48CA257483000D8463/ $File/ SafetyQualityHealthReformAgenda-web.pdf Accessed 26 Mar 2005.
28. Coombes I, Mitchell C, Stowasser D. Safe medication practice tutorials: a practical approach to preparing safe prescribers. Clin Teach 2007;4:128-34.
29. Rozich J, Howard R, Justeson J, et al. Standardisation as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004;30:5-14.
30. Reason J. Human error. Cambridge: Cambridge University Press, 1990.
31. Wears R, Berg M. Computer technology and clinical work-still waiting for Godot. JAMA 2005;293:1261-3.
32. Australian Council for Safety and Quality in Health Care. Second National Report on Patient Safety-Improving Medication Safety. Canberra: Australian Council for Safety and Quality in HealthCare, 2002.
33. Coombes ID, Pillans PI, Storie WJ, et al. Quality of medication ordering at a large teaching hospital. Aust J Hosp Pharm 2001;31:102-6.
34. Coombes I, Maclean C, Rigby D, et al. An audit of medication administration a comparison of automated and manual systems. The Society of Hospital Pharmacists of Australia 24th Federal Conference; 1998, Perth, Australia.
35. Lubliner M, Cole-Sinclair M, Kenneally A, et al. Minimising medication mishap: Introducing a warfarin safety strategy. J Pharm Pract Res 2005;34:266-70.
36. Coombes I, Heel A, Stowasser D, et al. Identification of medication errors by nurses-during a simulated ward, medication safety orientation program. J Pharm Pract Res 2005;35:190-5.
37. Barker KN, McConnell WE. Detecting errors in hospitals. American Journal of Hospital Pharmacy 1962;19:361-9.
38. Dean B, Schachter M, Vincent C, et al. Prescribing errors in hospital inpatients: their incidence and clinical significance. Qual Saf Health Care 2002;11:340-4.
39. Australian Medicines Handbook Pty Ltd. Australian medicines handbook. Mile End, SA: Adelaide Newstyle Printing, 2002.
40. van der Meer F, Rosendaal F, Vandenbroucke J, et al. Bleeding complications in oral anticoagulant therapy. Arch Intern Med 1993;153:1557-62.
41. Shulman R, Singer M, Goldstone J, et al. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005;9:R516-21.
42. Leape LL, Kabcenell AI, Gandhi TK, et al. Reducing adverse drug events: lessons from a breakthrough series collaborative. Jt Comm J Qual Saf 2000;26:321-31.