Volume 15, Issue 2 (6-2016)                   jhosp 2016, 15(2): 41-48 | Back to browse issues page

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azimi L, markazimoghaddam N, Rostami K, Talebi A, Eskandari A, Mirzaiy A et al . Assessing the Physicians' Order Errors in Medical Records and it's effective Factors (A Case Study). jhosp. 2016; 15 (2) :41-48
URL: http://jhosp.tums.ac.ir/article-1-5262-en.html
1- PhD in Health Care Services Management, Shahid Modarres Hospital, Shahid Beheshti University, Tehran, Iran (*Corresponding author), Tel: 09123110814, Email: leilaazimi15@yahoo.com, Address: Shahid Modarres Hospital, Cross Saadat Abad Ave. with Yadegar Emam Highway, Tehran, Iran , leilaazimi15@yahoo.com،
2- Assistant Professor, Aja University of Medical Sciences, Tehran, Iran
3- Assistant Professor, Shahid Modarres Hospital, Shahid Beheshti University, Tehran, Iran
4- PhD in Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University, Tehran, Iran
5- BSc in Medical Recording, Shahid Modarres Hospital, Shahid Beheshti University, Tehran, Iran
6- MSc, Chief in Public Relation, Shahid Modarres Hospital, Shahid Beheshti University, Tehran, Iran
Abstract:   (5485 Views)

Background: Nowadays, Patient Safety is considered as a fundamental concept of the healthcare system. Hence, recognizing the effective factors such as illegible orders, dosage errors, and drug usage can reduce serious side effects leading to the patients' disability, prolonged hospitalization and even death.

Materials and Methods: This descriptive-analytical study performed as a cross-sectional one. 1800 inpatient records selected in a teaching hospital during one year. The physician  first order was examined through a self-adminstrated checklist including physicians’ ID and workshifts, and variables  like legibility and recorded dosage. Data analysis conducted via SPSS using descriptive statistics and analytical statistics tests.

Results: Among 1800  studied records, there were 66.3% recorded by male, 17.6% illegible, 3.2% with no  stamp, 8.2% without signing, 11.9% without time and 4.9% with no date.23% of physician records didn't have coherence and logical sequence, 69.5% did not indicate to the primary items, 17.8% with no medicine dosage, 21.8% without pharmaceutical forms, 11.5% with no usage time, 25.9% without usage method, 14.3% had scribbles and 13% were devoid of numbering.  Also, there were a significant relation between demographic variables and some medical recording errors. 

Conclusion: it is necessary to endeavor physicians in patient records documentation improvement and can be used some strategies such as educating the newly arrived residents, considering commendatory techniques and record periodic evaluation.

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Type of Study: Case Study | Subject: سیاست گذاری ، برنامه ریزی و رهبری و مدیریت در بیمارستان
Received: 2014/05/5 | Accepted: 2016/03/17 | Published: 2016/05/21

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