[Correct documentation of drug prescriptions].

Area of Science:

• Healthcare quality improvement
• Medication safety
• Clinical documentation

Context:

• Discrepancies exist in drug prescription documentation between physicians and nurses.
• A retrospective audit revealed lower accuracy rates in nurses' drug lists (44%) compared to doctors' records (69%).

Purpose:

• To investigate and minimize documentation differences in drug prescriptions between doctors and nurses.
• To enhance the accuracy and safety of medication management within a healthcare department.

Summary:

• A retrospective audit identified significant prescription errors in both doctors' and nurses' documentation.
• A standardized prescription sheet and clinical guidelines were developed and implemented.
• Post-implementation, prescription accuracy increased to 91%, with 98% accuracy for doctor-signed prescriptions.

Impact:

• The common prescription sheet led to a highly significant improvement in drug prescription quality.
• The standardized approach enhanced medication safety and provided an updated survey of patient medications.
• No health-threatening prescription errors were detected after the intervention.