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Documentation error, technique error and wrong timing contributed for 315 (87.5 %), 263 (73.1 %), and 193 (53.6 %) of the medication administration errors, respectively (Fig. 1).
Data inspection showed no evidence of documentation errors of the cost values for the identified outliers.
We found an extremely high rate of documentation error.
According to the online survey of the Gesellschaft für Technische Dokumentation - tekom Deutschland e.V. tekom e.V. one to two thirds of all documentation errors are terminological errors [15].
The complexity of documentation, analysis, error rate and susceptibility to manipulation increase on the other hand.
documentation is full of errors," she said.
As an example, it is often unclear from chart documentation whether the error occurred because of a lack of monitoring or in the course of adhering to recommended medication monitoring.
The frequency of medical errors found in the medical records in the 12 clinics in Malaysia in this cross-sectional study of 1753 records was: documentation errors 98.0%; medication errors 41.1%, investigation errors 21.7%, decision making errors 14.5% and diagnostic errors 3.6%.
Documentation error was the most dominant type of error followed by technique and time error respectively.
Documentation error is the most dominant type of error observed during the study.
Of course, the use of CPOE systems cannot prevent every documentation error; it may even introduce new sources of error.
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Justyna Jupowicz-Kozak
CEO of Professional Science Editing for Scientists @ prosciediting.com