How to assure the quality of clinical records? A 7-year experience in a large academic hospital.

Introduction: Clinical record (CR) is the primary tool used by healthcare workers (HCWs) to record clinical information and its completeness can help achieve safer practices. CR is the most appropriate source in order to measure and evaluate the quality of care. In order to achieve a safety climate is fundamental to involve a responsive healthcare workforce thorough peer-review and feedbacks.

[Clinical and organizational guidelines in university hospitals: a model for classification and analysis of hospital records].

Clinical and organizational guidelines in university hospitals: a model for classification and analysis of hospital records.

Errors and omissions in hospital prescriptions: a survey of prescription writing in a hospital.

Background: The frequency of drug prescription errors is high. Excluding errors in decision making, the remaining are mainly due to order ambiguity, non standard nomenclature and writing illegibility. The aim of this study is to analyse, as a part of a continuous quality improvement program, the quality of prescriptions writing for antibiotics, in an Italian University Hospital as a risk factor for prescription errors.