Title

Prevalence of transcription errors in admitted patients at De La Salle University Medical Center in November 2015

Date of Completion

2016

Document Type

Thesis

Degree Name

Clinical Pharmacology

Keywords

Medical Transcription, Medical Records

Abstract

This study aimed to determine the prevalence of transciption errors in admitted patients at DLSUMC, particularly of those admitted patients in the 4 major departments, namely: Internal medicine, Obstetrics-Gynecology, Pediatrics, and Surgery in November 2015. The researchers focused on the errors on how the doctors prescribed their medication through chart orders. Prescriptions and doctor's orders were obtained in the Records division of De La Salle University Medical Center. In order to determine the errors, a checklist was used. A maximum of 4 prescriptions or 4 physician's order were evaluated for each patient. Patient's age, gender, and medications given during the stay in the ward were gathered. Two thousand twenty one different kinds of prescription errors were recorded. Most of the charts reviewed were from Internal Medicine department and it has the most number of errors recorded with 37.53% followed by Pediatrics (29.70%), Obstetrics (17.96%) and Surgery (14.8%) department. Error per chat was also tallied and result showed the Pediatrics department had the highest rate of error per chat with 21%, followed by Surgery, 16.53%, Internal Medicine (15.02%) and Obstetrics (14.65%) department. Most common prescription error committed by all departments were: PTR number and PRC license number were not written, proper capitalization of words was not observed and generic name was not written in full. The study concluded that transcription errors were common in medical practice regardless of the department although errors that could be considered severe are unusual.

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