Skriftlig dokumentation af medicinordinationer: Overensstemmelse imellem lœgejournal og Medicinkardex

Stig Ejdrup Andersen*, Dora Fog

*Corresponding author af dette arbejde

    Publikation: Bidrag til tidsskriftArtikelForskningpeer review

    Abstrakt

    A comparison of drug prescriptions entered on case records and nurses' drug lists is presented. Of 144 patients admitted to a general internal medicine ward, nine received no drugs. The remaining 135 had 606 (75,0%) items on both case record and drug list, 114 (14,1%) on the case record only, and 88 (10,9%) on the drug list only. For 48 patients (35,6%) drug lists were in accordance with their case record concerning the number and type of drug prescribed. Prescriptions on both documents were characterised by lack of accuracy. Of the 709 prescriptions on case records and 684 on drug lists, 428 (60,4%) and 411 (60,1%) respectively were unambiguous. Conclusion: Drug prescribing based on transcription from case records to nurses' drug lists implies a considerable risk of discrepancies. Thus, there is a significant risk of incorrect drug administration. A standardised card for drug prescriptions for common use by both physicians and nurses will therefore now be taken into use.

    Bidragets oversatte titelDrug prescriptions entered on case records and nurses' drug lists
    OriginalsprogDansk
    Sider (fra-til)4059-4062
    Antal sider4
    TidsskriftUgeskrift for laeger
    Vol/bind160
    Udgave nummer27
    StatusUdgivet - 29 jun. 1998

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