Analysis of the computerized prescription in two clinics of a teaching hospital

Abstract

Objective: To identify and analyze the writing of electronic orders in a universityhospital in São Paulo State and propose suggestions to improve the system. Study model: Evaluative study. Study site: The study was conducted in two clinics at the University Hospital of the Faculty of Medicine of Ribeirão Preto – University of São Paulo - and its object of analysis consisted of electronic orders. Population and sample: 390 orders were analyzed in the orthopedics clinic and 535 orders were evaluated in the medical clinic, which corresponded to all orders evaluated in 30 nonconsecutive days. Results: Of the total number of 925 orders evaluated in the two clinics, 112 (12.1%) presented erasures, 129 (13.9%) showed medication suspensions introduced either manually or in typing, 261 (28.2%) presented information that made professionals doubtful, among others. Conclusions: Electronic orders represent a great advancement in the strategies used to minimize errors resulting from badly formulated orders. However, it does not eradicate the possibility of occurrence of medication errors; which indicates that modifications in the system are necessary.