Andersen S E, Fog D
H:S Amager Hospital, medicinsk afdeling.
Ugeskr Laeger. 1998 Jun 29;160(27):4059-62.
A comparison of drug prescriptions entered on case records and nurses' drug lists is presented. Of 144 patients admitted to a general internal medicine ward, nine received no drugs. The remaining 135 had 606 (75.0%) items on both case record and drug list, 114 (14.1%) on the case record only, and 88 (10.9%) on the drug list only. For 48 patients (35.6%) drug lists were in accordance with their case record concerning the number and type of drug prescribed. Prescriptions on both documents were characterised by lack of accuracy. Of the 709 prescriptions on case records and 684 on drug lists, 428 (60.4%) and 411 (60.1%) respectively were unambiguous.
Drug prescribing based on transcription from case records to nurses' drug lists implies a considerable risk of discrepancies. Thus, there is a significant risk of incorrect drug administration. A standardised card for drug prescriptions for common use by both physicians and nurses will therefore now be taken into use.
本文呈现了病例记录上录入的药物处方与护士药物清单的对比情况。在入住普通内科病房的144名患者中，9人未接受任何药物治疗。其余135名患者中，病例记录和药物清单上都有的项目有606项（占75.0%），仅病例记录上有的项目有114项（占14.1%），仅药物清单上有的项目有88项（占10.9%）。48名患者（占35.6%）的药物清单在处方药物的数量和类型方面与病例记录一致。两份文件上的处方都存在准确性不足的问题。病例记录上的709份处方和药物清单上的684份处方中，分别有428份（占60.4%）和411份（占60.1%）是明确无误的。
从病例记录转录到护士药物清单的药物处方存在相当大的差异风险。因此，存在药物给药错误的重大风险。因此，现在将启用医生和护士共同使用的标准化常用药物处方卡。
