Journal of

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Background: 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 reduce serious side effects leading to the patients' disability, prolonged hospitalization and even death.

Materials and Methods: This descriptive-analytical study performed as a cross-sectional one. 1800 inpatient records selected in a teaching hospital during one year. The physician  first order was examined through a self-adminstrated checklist including physicians’ ID and workshifts, and variables  like legibility and recorded dosage. Data analysis conducted via SPSS using descriptive statistics and analytical statistics tests.

Results: Among 1800  studied records, there were 66.3% recorded by male, 17.6% illegible, 3.2% with no  stamp, 8.2% without signing, 11.9% without time and 4.9% with no date.23% of physician records didn't have coherence and logical sequence, 69.5% did not indicate to the primary items, 17.8% with no medicine dosage, 21.8% without pharmaceutical forms, 11.5% with no usage time, 25.9% without usage method, 14.3% had scribbles and 13% were devoid of numbering.  Also, there were a significant relation between demographic variables and some medical recording errors. 

Conclusion: it is necessary to endeavor physicians in patient records documentation improvement and can be used some strategies such as educating the newly arrived residents, considering commendatory techniques and record periodic evaluation.

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Background: Medical errors represent a serious problem for intensive care and increase the length of stay and mortality. Tracking of medical errors in hospital have focused on voluntary reporting of errors, but 10 to 20 % of errors are ever reported and, of those, 90-95 percent cause no harm to patients. This study was conducted to recognition and analysis medical errors in Intensive Care Unit by GTT in 2019.   
Materials & Methods: This study was a retrospective descriptive-experimental and was conducted in the Intensive Care Unit of a public hospital in Tehran. In 2019 for 13 weeks,127 records were separately reviewed by two nurses by using the IHI checklist and final confirmation was performed by the physician. The data were analyzed by SPSS 22 software.
 Results. 622 triggers, 277 adverse events related to triggers, 121 adverse events without trigger and totally 398 adverse events were identified in ICU. 93 records from 127 records had adverse events. The incidence rate of adverse events was 73/2%, 3/13 adverse events per pa­tient and the incidence rate was 24/8 adverse events per 100 patients-day. The most frequency of events and harms were respectively related to care, intensive care, surgery and medication modules.
Conclusion. According to the result of patient records reviewing and the high rate of AEs that required intervention and also the result of similar study, we can state this tool is more reliable than other methods to detect AEs, such as voluntary reporting of error.