A retrospective audit of medication prescription records in critical care units of a tertiary hospital in the Cape metropole

Spogter, Aletta Beverley (2017-03)

Thesis (MCur)--Stellenbosch University, 2017.

Thesis

ENGLISH SUMMARY : Prescribing and administering medications in a critical care unit is a challenge due to the complexity of the patient’s condition. Management of medication prescription records involves the doctor, nurse and pharmacist. The doctor prescribes medication and the pharmacist reviews the prescription to detect possible errors and provides guidance. The nurse interprets the prescription and administers the medication. Failure in this may compromise the safety and quality of patient care. The purpose of this study was to retrospectively audit the medication prescription records of patients in critical care units of a tertiary hospital in the Cape Metropole. The objectives of this study were to determine whether the documentation of: • medication prescription records are accurately completed by the doctors • medication prescription records are accurately completed by the nursing staff • pharmacology requirements by pharmacy staff are accurately completed • antibiotic stewardship prescription records are accurately completed • high alert medication records are accurately completed A retrospective descriptive research design with a quantitative approach was applied to audit the status of medication prescription records of patients in six critical care units at the hospital under study. The target population included the prescription medication prescription records of all patients (N = 1276) who were admitted to and discharged from the six CCUs between 1 July 2013 and 31 December 2013. With the support of a statistician n=255(20%) probability sample using a systematic sampling method was applied to draw the files of patients from the six CCUs. However, due to files not obtainable a final sample size of 13.6% (n=174) was available for the auditing process. The researcher collected data personally using a self-designed audit instrument that met specific standards of the prescription records of patients in CCUs. The reliability and validity were assured through experts in nursing science, intensive care nursing, a statistician, a research methodologist and a pilot study. Ethical approval for conducting the study was obtained from the Health Research Ethics Committee of the University of Stellenbosch and a waiver of consent to work on the patients’ files was granted (Reference number: S14/06/132), as well as from the tertiary hospital (Annexure C). Descriptive and inferential analyses were performed with the support of the statistician, utilising the SPSS version 22 (IBM) program. Results are presented in bar graphs and tables. Comparisons of variables were done with the application of the ANOVA, post-hoc Bonferroni on a 95% confidence interval. The results of the study showed that none of the medication prescription records were 100% completely documented. Incomplete status varied between all the role players. Illegible handwriting throughout medication prescription records n=27(16%) was still evident. Furthermore, failure to correctly acknowledge medication documentation errors is still high amongst role players. Doctors fail to sign (85%) and indicate date of error (92%), nurses fail to sign (98%) and indicate date of error (96%), while pharmacists fail to sign (62%) and indicate date of error (66%) on files applicable to each one. Recommendations to improve documentation on medication prescription include the introduction of continuous quality improvement programme, staff orientation and induction to CCU, in-service training for all staff and ensuring a just culture.

AFRIKAANSE OPSOMMING : Die voorskryf en toedien van medisyne in ‘n kritieke sorgeenheid is ‘n uitdaging, weens die kompleksiteit van die pasient se mediese toestand. Die hantering van mediese rekords betrek die dokter, verpleegster en apteker. Die dokter skryf medisyne voor en die apteker gee ‘n oorsig van die voorskrif om moontlike foute uit te skakel en om leiding te verskaf. Die verpleegster interpreteer die voorskrif en gee die medisyne. Indien daar versuim word om dit uit te voer, kan die veiligheid en kwaliteit van die pasient se sorg gekompromitteer word. Die doel van hierdie studie was om in retrospeksie, die voorskrifmedisyne-rekords van pasiente in intensiewe sorgeenhede aan ‘n tersiere hospitaal in die Kaapse Metropoolgebied te oudit. Die doelwitte van hierdie studie was om vas te stel of die dokumentasie van: • voorskrifmedisyne-rekords akkuraat deur dokters voltooi is • voorskrifmedisyne-rekords akkuraat deur verpleegpersoneel voltooi is • farmakologiese vereistes deur apteekpersoneel akkuraat voltooi is • die verantwoordelike bestuur van antibiotikums volgens voorskrifrekords akkuraat voltooi is • hoe waarskuwing medikasie rekords is korrek voltooi is ‘n Retrospektiewe beskrywende ontwerp met ‘n kwantitatiewe benadering is toegepas om die status van voorskrifmedisyne-rekords van pasiente in ses intensiewe sorgeenhede by die hospitaal onder die soeklig te oudit. Die teikenbevolking sluit in die voorskrifmedisyne-rekords van al die pasiente aan die ses kritieke sorgeenhede (N= 1276) wat opgeneem en ontslaan is tussen 1 Julie 2013 en 31 Desember 2013. Met die hulp van ‘n statistikus is ‘n 20% (n=255) waarskynlikheidssteekproef deur ‘n sistematiese steekproefmetode gebruik om al die leers van pasiente van die ses kritieke sorgeenhede te trek. Nietemin, omdat leers nie verkry kon word nie, is ‘n finale steekproefgrootte van 13.6% (n=174) beskikbaar vir die ouditproses gestel. Die navorser het data persoonlik gekollekteer deur ‘n self-ontwerpte oudit-instrument te gebruik wat aan spesifieke standaarde van voorskrifrekords van pasiente in kritieke sorgeenhede voldoen. Die betroubaarheid en geloofbaarheid is verseker deur kundiges in verpleegwetenskap, intensiewe sorgverpleging, ‘n statistikus, ‘n navorsingsmetodoloog en ‘n loodsondersoek. Etiese goedkeuring vir die navorsing van die studie is verkry van die Gesondheidsnavorsingsetiek-komitee van die Universiteit van Stellenbosch en ‘n kwytskelding vir toestemming om te werk aan pasiente se leers is goedgekeur (Verwysing nr S14/06/132), asook van die tersiere hospitaal (Anneks C). Beskrywende en afgeleide analises is met die hulp van die statistikus uitgevoer deur gebruik te maak van die SPSS weergawe 22 (IBM) program. Die resultate van die ondersoek het getoon dat nie een van die voorskrifmedisyne-rekords 100% voltooi is nie. Uitslae is in staafgrafieke en tabelle aangebied. Vergelykings van variante is met die toepassing van die ANOVA, posthoc Bonferroni op ‘n 95% betroubaarheidsinterval gedoen. Die onvoltooide status het gevarieer en by alle rolspelers voorgekom. Onleesbare handskrifte is in die voorskrifmedisyne-rekords (n=27/16%) bespeur. Voorts word daar nagelaat om ruiterlik te erken dat foute in die dokumentering van voorskrifmedsyne onder rolspelers beduidend voorkom. Dokters versuim om te teken (85%) en om die datum van die fout aan te dui (92%), verpleegsters versuim om te teken (98%) en om die datum van die fout aan te dui (96%), terwyl aptekers versuim om te teken (62%) en om die datum van die fout aan te dui (66%) op leers wat vir elkeen van toepassing is. Aanbevelings om dokumentasie oor voorskrifmedisyne te verbeter, sluit in die instel van voortdurende programme om die kwaliteit te verbeter; personeelorientasie en induksie tot die kritieke sorgeenheid (KSE); indiensopleiding vir alle personeellede en die versekering van ‘n regverdige kultuur.

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