Table 2

Errors detected in audited medical records
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

Khoo et al.

Khoo et al. BMC Family Practice 2012 13:127   doi:10.1186/1471-2296-13-127

Open Data