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Table 2 Errors detected in audited medical records

From: Medical errors in primary care clinics – a cross sectional study

 

N

Error rate

Inconclusive rate

%

95% CI (%)

%

95% CI (%)

Overall documentation errors

1753

98.0

97.0 – 99.1

-

-

No/Inadequate History

1753

46.5

29.7 – 63.2

-

-

No/Inadequate Physical examination

1753

51.2

36.3 – 66.1

-

-

No/Inadequate Diagnosis

1753

42.5

24.7 – 60.2

-

-

Overall management errors

1753

53.2

46.3 – 60.2

13.9

9.0 – 18.8

Medication errors

1753

41.1

35.8 – 46.4

27.9

20.3 – 35.4

Wrong dosage/frequency prescribed

 

48.5

41.5 – 55.6

  

Inappropriate medication prescribed

 

47.2

39.0 – 55.4

  

Drug interaction/adverse reactions

 

9.8

5.1 – 14.4

  

Investigation errors

1753

21.7

16.5 – 26.8

22.3

14.8 – 29.7

No investigation done

 

72.6

68.1 – 77.1

  

Unnecessary investigation done

 

8.6

4.7 – 12.6

  

Decision making errors

1753

14.5

10.8 – 18.2

40.2

30.4 – 49.9

Inappropriate follow up

 

48.4

37.7 – 59.1

  

Inappropriate care plan

 

8.1

4.0 - 12.2

  

Referral not made when it should

 

6.3

3.1 – 9.4

  

Referral for admission not done

 

3.6

0 - 7.7

  

Diagnostic errors

1753

3.6

2.2 – 5.0

61.9

53.2 – 70.6