Background Prescribing error may result in adverse clinical
outcomes leading to increased patient morbidity, mortality
and increased economic burden. Many errors occur
during transitional care as patients move between different
stages and settings of care.
Aim To conduct a review of medication information and
identify prescribing error among an adult population in an
Methods Retrospective review of medication information
was conducted. Part 1: an audit of discharge prescriptions
which assessed: legibility, compliance with legal requirements,
therapeutic errors (strength, dose and frequency)
and drug interactions. Part 2: A review of all sources of
medication information (namely pre-admission medication
list, drug Kardex, discharge prescription, discharge letter)
for 15 inpatients to identify unintentional prescription
discrepancies, defined as: ‘‘undocumented and/or unjusti-
fied medication alteration’’ throughout the hospital stay.
Results Part 1: of the 5910 prescribed items; 53 (0.9%)
were deemed illegible. Of the controlled drug prescriptions
11.1% (n = 167) met all the legal requirements. Therapeutic
errors occurred in 41% of prescriptions (n = 479)
More than 1 in 5 patients (21.9%) received a prescription
containing a drug interaction. Part 2: 175 discrepancies
were identified across all sources of medication information;
of which 78 were deemed unintentional. Of these:
10.2% (n = 8) occurred at the point of admission, whereby
76.9% (n = 60) occurred at the point of discharge.
Conclusions The study identified the time of discharge as a
point at which prescribing errors are likely to occur. This
has implications for patient safety and provider work load
in both primary and secondary care.