Ansari Mukhtar, Neupane D
Department of Pharmacology, Nobel Medical College & Teaching Hospital, Kanchanbari, Biratnagar (Morang), Nepal.
Kathmandu Univ Med J (KUMJ). 2009 Jul-Sep;7(27):238-41. doi: 10.3126/kumj.v7i3.2730.
Prescription writing is one of the most important and basic skills that a doctor needs. Prescribing errors may have various detrimental consequences. Hence, the components of a prescription should be clearly written, free of drug related omission (incomplete prescription), commission (incorrect information) and integration errors, without nonofficial abbreviations, and fulfil the legal requirements of a prescription. Since errors of prescribing are the commonest form of avoidable medication errors, it is the most important target for improvement.
To estimate the types and prevalence of medication errors during transcription.
A cross sectional descriptive retrospective study was conducted at Nobel Medical Teaching Hospital, Biratnagar, Nepal during a time period from 15th November 2008 to 14th February 2009. A random sample of 268 prescriptions of patients written during a period of one year (18/06/2007 to 17/06/2008) for ten different medical out patient departments of the Hospital were reviewed and the analysis was carried out for determining the different types of errors in writing a prescription.
No error was found regarding the name, age, sex and address of the patients. The error in prescriptions regarding the prescriber's name, qualification, NMC registration number and signature were 85.4%, 99.6%, 99.6% and 15.7% respectively. Similarly, the symbol Rx was missing in 66.8%. Dosage form, quantity, dose, frequency and route of administration were not mentioned in 12%, 60%, 19%, 10% and 63% of the prescriptions respectively. Likewise, strength of the prescribed medicines was not stated in 40% of the cases.
There is a need to critically address the legibility of prescription, correct spelling of drugs, authorised abbreviations and all other informations of a prescription concerned with patient, prescriber and drugs to minimise the occurrence of medication errors.
处方书写是医生所需掌握的最重要且最基本的技能之一。开方错误可能会产生各种有害后果。因此，处方的各项内容应清晰书写，避免与药物相关的遗漏（处方不完整）、错误（信息不正确）和整合错误，不使用非官方缩写，并符合处方的法律要求。由于开方错误是可避免的用药错误中最常见的形式，所以它是改进的最重要目标。
评估转录过程中用药错误的类型和发生率。
于2008年11月15日至2009年2月14日期间，在尼泊尔比拉德讷格尔的诺贝尔医学教学医院开展了一项横断面描述性回顾性研究。随机抽取了该医院十个不同门诊科室在一年时间（2007年6月18日至2008年6月17日）内开具的268份患者处方进行审查，并进行分析以确定处方书写中的不同错误类型。
在患者姓名、年龄、性别和地址方面未发现错误。处方中关于开方者姓名、资质、国家医学委员会注册编号和签名的错误率分别为85.4%、99.6%、99.6%和15.7%。同样，“Rx”符号缺失的情况占66.8%。分别有12%、60%、19%、10%和63%的处方未提及剂型、数量、剂量、频次和给药途径。同样，40%的病例未注明所开药物的规格。
有必要严格关注处方的易读性、药物的正确拼写、授权缩写以及与患者、开方者和药物相关的处方所有其他信息，以尽量减少用药错误的发生。
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