A retrospective audit of medication prescription records in critical care units of a tertiary hospital in the Cape metropole

[摘要] ENGLISH SUMMARY : Prescribing and administering medications in a critical care unit is a challenge due to the complexity of the patient's condition. Management of medication prescription records involves the doctor, nurse and pharmacist. The doctor prescribes medication and the pharmacist reviews the prescription to detect possible errors and provides guidance. The nurse interprets the prescription and administers the medication. Failure in this may compromise the safety and quality of patient care. The purpose of this study was to retrospectively audit the medication prescription records of patients in critical care units of a tertiary hospital in the Cape Metropole. The objectives of this study were to determine whether the documentation of:• medication prescription records are accurately completed by the doctors• medication prescription records are accurately completed by the nursing staff• pharmacology requirements by pharmacy staff are accurately completed• antibiotic stewardship prescription records are accurately completed• high alert medication records are accurately completedA retrospective descriptive research design with a quantitative approach was applied to audit the status of medication prescription records of patients in six critical care units at the hospital under study. The target population included the prescription medication prescription records of all patients (N = 1276) who were admitted to and discharged from the six CCUs between 1 July 2013 and 31 December 2013. With the support of a statistician n=255(20%) probability sample using a systematic sampling method was applied to draw the files of patients from the six CCUs. However, due to files not obtainable a final sample size of 13.6% (n=174) was available for the auditing process. The researcher collected data personally using a self-designed audit instrument that met specific standards of the prescription records of patients in CCUs. The reliability and validity were assured through experts in nursing science, intensive care nursing, a statistician, a research methodologist and a pilot study. Ethical approval for conducting the study was obtained from the Health Research Ethics Committee of the University of Stellenbosch and a waiver of consent to work on the patients' files was granted (Reference number: S14/06/132), as well as from the tertiary hospital (Annexure C). Descriptive and inferential analyses were performed with the support of the statistician, utilising the SPSS version 22 (IBM) program. Results are presented in bar graphs and tables. Comparisons of variables were done with the application of the ANOVA, post-hoc Bonferroni on a 95% confidence interval. The results of the study showed that none of the medication prescription records were 100% completely documented. Incomplete status varied between all the role players. Illegible handwriting throughout medication prescription records n=27(16%) was still evident. Furthermore, failure to correctly acknowledge medication documentation errors is still high amongst role players. Doctors fail to sign (85%) and indicate date of error (92%), nurses fail to sign (98%) and indicate date of error (96%), while pharmacists fail to sign (62%) and indicate date of error (66%) on files applicable to each one.Recommendations to improve documentation on medication prescription include the introduction of continuous quality improvement programme, staff orientation and induction to CCU, in-service training for all staff and ensuring a just culture.

[发布机构] Stellenbosch University