RESUMO
BACKGROUND: Faults in writing prescriptions are a common source of medical error. Iatrogenic injury due to medication error increases patient morbidity and hospital stay, thereby encouraging litigation. AIM: To assess the accuracy and legibility of the prescriptions in patients' medication charts. METHODS: A cross-sectional observational study examined prescribing records of inpatients randomly selected in two surgical wards. Medication charts were assessed by a committee consisting of a nurse, a pharmacist and a doctor for omission and legibility of prescribing information. RESULTS: Important patient information and medication administration details were frequently omitted from charts. Overall, 27% of individual prescriptions had potential to cause prescription error because of illegibility or omission of medication administration details. CONCLUSIONS: The results of this study demonstrate that prescription error frequently occurs in the clinical workplace and may contribute to medical error. Improving legibility of handwriting and use of novel prescribing devices may reduce prescription error.
