A prescrição médica eletrônica em um hospital universitário: falhas de redação e opiniões de usuários

Abstract

This study analyzed the writing failure of the computerized physician order entry system and its advantages and disadvantages according to users. At a university hospital 1,351 physician orders were analyzed and 84 nursing and medical professionals were interviewed. The results showed that 17.7% of the orders presented measures, medication had been suspended in 16.8%, in 28.2% there was dubious or misleading information and in 25% medication had been prescribed manually. The professionals indicated advantages such as: ease of data reading and the quickness with which the order is entered and released, among others. They also reported disadvantages such as the repetition of orders from previous days without a review and incorrectly typed information. Therefore, it is concluded that, despite representing an important strategy for error reduction, this system must be overhauled and professionals must be trained to use it.

Prescription errors in Brazilian hospitals: a multi-centre exploratory survey

“…The interruption of prescriptions was the most common change found in this study and it occurred at all hospitals, including hospital A. This data was confirmed by the literature that demonstrated that interruptions of the drug regimen were not reduced by electronic prescriptions 35,39 . So, Lesar 28 highlighted the need to confirm prescription changes or interruptions, from the discussion between the pharmacist and physician.…”

“…It may cause confusion, which goes against the Brazilian medical ethics code which establishes that the doctor is responsible for prescribing clearly and legibly and, therefore, without erasures 40 . Despite this, previous studies showed that erasures are common in Brazilian prescriptions 13,20,35 . Sometimes a 'free text' feature can be used to substitute erasures in prescriptions.…”

“…Although it saves time and space, using abbreviations may sometimes turn out to be very expensive, as they may be misinterpreted, have double meanings, be confusing and give rise to errors 32,33,34 . Some studies mentioned difficulties in making the following distinctions on handwritten prescriptions: comp (tablets) vs. amp (flask); caps (capsules) vs. comp (tablets); sup (suppositories) vs. susp (suspension), which can lead to incorrect routes of administration and/or techniques 19,31,35 . In 2007, ANVISA discussed the establishment of standards for abbreviations in prescriptions 36 .…”

Influência da redação da prescrição médica na administração de medicamentos em horários diferentes do prescrito

“…Erasures have also been identified to affect patient safety because they may cause misreading of information included in the prescription (3,9) .…”

“…An appropriate medication prescription is key for preventing these events because ambiguous, illegible or incomplete prescriptions as well as non-harmonized nomenclature of drug prescribed (brand vs. generic name), use of abbreviations and erasures are all well-known factors that can be associated with adverse events (2)(3) . Studies have showed that the administration of medication at different times than what was prescribed is the most common adverse event during the administration step (4)(5) .…”