> medical center. Methods. During a 2-month study period, we collected
copies of prescriptions and DCIs. We also called care givers after
discharge and asked them to read the medication labels that were filled
from discharge prescriptions. Care givers were also asked whether they
received instruction from community pharmacists. Results., Data were
collected on 335 prescriptions for 192 patients. Differences among the
prescriptions, DCIs, and medication labels were found for 40 (12%) of
the medications prescribed at discharge, representing 19% of the
patients studied. Nineteen prescriptions had prescriber errors in dosing
frequencies or dosage formulations. Three prescriptions were filled with
different medication concentrations or strengths than requested.
Prescriptions were altered by the community pharmacists for unexplained
reasons in 6 cases, whereas the DCIs and original prescriptions differed
in 12 cases. Only 44% of families were counseled about proper medication
administration by their pharmacists. Conclusions. A potential for
medication errors exists when pediatric patients are discharged with
unfilled prescriptions. The potential may be worsened when discharge
instructions are created from a prescription rather than from the label
of a dispensed medication. Educational and risk-management efforts
should emphasize the importance of writing complete, legible
prescriptions and consulting appropriate reference materials to ensure
that dose formulations and guidelines are accurate. Whenever possible,
prescriptions should be filled before patients are discharged, so that
the dispensed medications can be reviewed, and health care providers can
provide accurate discharge instructions. Pediatrics 1996; 97:481-485;
medication errors, pediatrics, residency education, nursing.
Full Text COPYRIGHT American Academy of Pediatrics 1996
Despite efforts to minimize...