Improving practice and patient safety through a medication systems review

Aim To identify areas of practice that could be improved upon, thereby reducing the risk of medication errors and improving patient safety.Method An observational study of medication administration took place over five medication rounds, to collect data on  interruptions and errors. A retrospective audit of medication documentation was conducted to collect data on the prescribing and recording of medication. The data collection took place over three afternoons and included all prescribing and recording sheets for 20 patients.Results During the observation study two errors were observed, one wrong time error and one quality of prescription error. Interruptions were classified as avoidable and unavoidable, and common themes identified. The medication documentationaudit exposed a number of serious issues such as allergies not being recorded on 79 (85%) prescription sheets and 103 (22%) parenteral medicines being prescribed in an inappropriate area of the prescription sheet. Conclusion The review has highlighted areas of practice, which, if improved upon, will not only reduce the risk of medication errors but also improve practice and patient safety.

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