691 Audit of Drug Chart Completion in General Surgery
نویسندگان
چکیده
Abstract Introduction The accuracy of drug charts is crucial for good clinical practice. General Medical Council states, doctors must keep clear, accurate and legible records, also applying to prescriptions. This audit quantified the chart completion in a Surgery Department within District Hospital. Method Single-centre retrospective assessment November 2019, assigning binary outcomes each domain: “100% complete” (all details such as name, dose, unit, route, frequency, indication, duration, signatures) vs. “incomplete”. After analysis (Microsoft Excel/IBM SPSS v.24), results were circulated locally, followed by re-audit during June-August 2020. Results Comparison (n = 22) 25) across 17 domains demonstrated higher rates 7 domains: Alerts/allergies (4/22:18% 18/25:72%; p < 0.001), signatures (2/22:9% 17/25:68%; venous thromboembolism risk (5/22:24% 24/25:96%; antithrombotic (0/21 9/25:36%; 0.002), regular (1/22:5% 10/25:40%; 0.04), as-required 5/22:23%; 0.020) medication intravenous fluids (1/16:6% 20/21:95%; 0.001). Performance 10 was not significantly different (p ≥ 0.05). Conclusions Standard documents like may appear at first glance. However, when assessed with strict criteria, performance suboptimal. Simple, cost-effective educational interventions can improve accuracy, positive implications patient safety.
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ژورنال
عنوان ژورنال: British Journal of Surgery
سال: 2021
ISSN: ['1365-2168', '0007-1323']
DOI: https://doi.org/10.1093/bjs/znab134.470