BACKGROUND/ OBJECTIVE: Discrepancies in records used within the medication use system have been identified as a contributing factor of medication errors. The objective of this study was to determine the frequency and type of discrepancies in the medication use system in one tertiary care hospital. METHODS: Using a sample of patients (convenience sampling technique), the physician's orders, the nursing medication administration record and the pharmacy profile were compared in an attempt to identify discrepancies among them. A discrepancy was defined as a deviation from the physician's order as written in the chart. Each discrepancy was categorized according to seven components of the medication order, its location in the medication use process and its mode of delivery. RESULTS: One thousand, four hundred twenty-four orders representing 197 patients from 13 nursing units were sampled for this study. Thirteen percent of the orders were discrepant and 61% of patients had at least one discrepancy. The most frequent types of discrepancies were drug omissions and unordered drugs. DISCUSSION: The discrepancies identified in this study suggest that either orders are not reaching pharmacy or orders are not being processed appropriately in pharmacy. The location of discrepancies also suggests that there are deficiencies in communication between healthcare professionals.
BACKGROUND/ OBJECTIVE: Discrepancies in records used within the medication use system have been identified as a contributing factor of medication errors. The objective of this study was to determine the frequency and type of discrepancies in the medication use system in one tertiary care hospital. METHODS: Using a sample of patients (convenience sampling technique), the physician's orders, the nursing medication administration record and the pharmacy profile were compared in an attempt to identify discrepancies among them. A discrepancy was defined as a deviation from the physician's order as written in the chart. Each discrepancy was categorized according to seven components of the medication order, its location in the medication use process and its mode of delivery. RESULTS: One thousand, four hundred twenty-four orders representing 197 patients from 13 nursing units were sampled for this study. Thirteen percent of the orders were discrepant and 61% of patients had at least one discrepancy. The most frequent types of discrepancies were drug omissions and unordered drugs. DISCUSSION: The discrepancies identified in this study suggest that either orders are not reaching pharmacy or orders are not being processed appropriately in pharmacy. The location of discrepancies also suggests that there are deficiencies in communication between healthcare professionals.