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Design, implementation and evaluation of a new drug chart in an intensive care/high-dependency unit


A 24-hour flow chart has been used for prescribing and documenting medication administration in the intensive therapy unit/high-dependency unit for many years. Transcription errors arising from rewriting inpatient drug charts have been recognised as a major factor contributing to medication errors. A project was undertaken to assess these errors in order to devise a new chart that would minimise them and improve patient safety.


An interdisciplinary group of medical, nursing and pharmacy staff designed a new drug chart for the pilot. Audit data were collected before and after the introduction of the new drug chart using categories from a similar study [1]. The errors recorded included: transcription errors (for example, transcription omission, or drug name, dose or dose frequency transcribed/altered incorrectly); administration errors (for example, doses given after prescription discontinued or prescribed dose not given); and patient's allergies not documented. Data were collected for 10 days. The number of patient-days was used as the denominator.


The audit showed that the new drug chart led to significant reductions in transcription errors and drug administration errors. There was an improvement in the documentation of allergies (Allergy) on patients' charts (Table 1).

Table 1 Transcription and administration errors before and after the new chart


The introduction of a drug chart designed by the interdisciplinary team has led to a substantial reduction in prescribing and administration errors and has improved patient safety. An audit cycle has been implemented and the team will continue to assess audit data and feedback from users to ensure that the design meets the evolving requirements of the intensive therapy unit/high-dependency unit and that reduction in prescribing and administration errors are sustained.


  1. 1.

    Colpaert K, et al.: Impact of a computerised physician order entry on medication prescription errors in the intensive care unit: a controlled cross sectional trial. Crit Care 2006, 10: R21. 10.1186/cc3983

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Ging, P., McGuirk, M., Marsh, B. et al. Design, implementation and evaluation of a new drug chart in an intensive care/high-dependency unit. Crit Care 12, P429 (2008).

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  • Flow Chart
  • Medication Error
  • Substantial Reduction
  • Prescribe Dose
  • Dose Frequency