abdallah mirzaiy

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 contribute to reducing the serious side effects leading to the patient's disability, prolonged hospitalization, and even death.
as a descriptive-analytical study, this research was cross-sectionally conducted with a sample of 1800 inpatient records in a teaching hospital during one year. The primary physician orders were examined through a self-managed checklist, including the items, such as: physicians’ ID and workshifts, and variables of legibility and recorded dosage. Data were processed via SPSS, regarding the descriptive statistics (like: frequency, …) and analytical statistics (like: chi-square, …).
of 1800 inpatient's records, 66.3% recorded by male, 17.6% records were illegible, 3.2% without stamping, 8.2% without signing, 11.9% without time, 4.9% without dating, 23% were not coherence and logical sequence 69.5% had not indicated to the 7 primary items, 17.8% without medicine dosage, 21.8% without pharmaceutical forms, 11.5% without usage time, 25.9% without usage method, 14.3% had scribbles and 13% lacked numbering also there were relation between demographic variables and medical recording errors .
it seems necessary for the physicians to try to improve the documentation of the patient records, such as: educating the newly arrived resident, considering commendatory techniques, and evaluating the records periodically.