Resumen de Errors in medication administration recording in a university hospital
Noelia Vicente Oliveros, Eva Delgado Silveira, Covadonga Pérez Menéndez Conde, Ana M. Álvarez Díaz, Sagrario Martín-Aragón
Background: Poor nursing documentation can place patients, staff and organizations at considerable risk of physical and legal harm. Objectives: To describe the errors in the Medication Administration Record (MAR) in different hospitalization units by classifying and evaluating them. As a second objective, we compared MAR errors detected in surgical and medical hospitalization units. Method: An observational and prospective study in a surgical and a medical hospitalization units during one month. Both units had Computerized Prescription Order Entry (CPOE) and Automated Dispensing Cabinet (ADC). MAR errors were classified according to the taxonomy defined by Ruiz-Jarabo 2000 group. For detecting MAR errors, a pharmacist reviewed the administration chart and the list of medication withdrawal from ADC the following day of administration. The administration chart was checked to match the prescription and with the list of medication withdrawal per patient. The discrepancies that were found were clarified with the involved staff to discover the cause. Moreover, the number of MAR errors detected in the surgical unit were compared with those of the medical unit. Results: We analyzed 1,185 doses from 68 patients. The error rate was 15.4%. The most common type of error was the omission of administration record (93%), mainly caused by procedural failure (66.3%). Error rates were higher in the surgical hospitalization unit than in the medical one. This difference was statistically significant (p <0.001). Conclusion: Omission of administration record was the most common type of MAR errors. The main cause was procedural failure. MAR errors were more frequent in the surgical hospitalization unit
