Survey of medication documentation at hospital discharge: implications for patient safety and continuity of care
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Medication discrepancies at the time of hospital discharge are common and can result in error, patient/carer inconvenience or patient harm. Providing accurate medication information to the next care provider is necessary to prevent adverse events.
To investigate the quality and consistency of medication details generated for such transfer from an Irish teaching hospital.
This was an observational study of 139 cardiology patients admitted over a 3 month period during which a pharmacist prospectively recorded details of medication inconsistencies.
A discrepancy in medication documentation at discharge occurred in 10.8% of medication orders, affecting 65.5% of patients. While patient harm was assessed, it was only felt necessary to contact three (2%) patients. The most common inconsistency was drug omission (20.9%).
Inaccuracy of medication information at hospital discharge is common and compromises quality of care.
Keywords“Continuity of patient care” Drug therapy Hospital communication systems Medication errors Patient discharge
Completion of this study would not have been possible without the help of nursing, pharmacy, medical and administrative staff in the study hospital. The authors also wish to acknowledge the time and input of those involved in assessing the clinical importance of medication errors.
- 4.Duggan C, Feldman R, Hough J, Bates I (1998) Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract 6:77–82Google Scholar
- 5.Colemann A (2002) Discharge information needs to be improved to prevent prescribing errors. Pharm J 268:81–86Google Scholar
- 8.Smith J (2004) Building a safer NHS for patients: improving medication safety: Department of Health (UK)Google Scholar
- 9.Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2006 National Patient Safety Goals, Goal 8 hospital version accurately and completely reconcile medications across the continuum of care http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_cah.htm. Accessed 23 Nov 2006
- 12.Sexton J, Brown A (1999) Problems with medicines following hospital discharge: not always the patient’s fault? J Soc Adm Pharm 16(3/4):199–207Google Scholar
- 15.Tully MP, McElduff P (2005) Identification of prescribing errors at different stages of hospital admission. IJPP 13:R29 (abstract)Google Scholar
- 16.Reason J (1997) Managing the risks of organisational accidents. Ashgate, VermontGoogle Scholar
- 17.Cohen MR (2007) Medication errors, 2nd edn. American Pharmacists Association, WashingtonGoogle Scholar
- 21.Donyai P, O Grady K, Jacklin A, Barber N, Franklin BD (2007) The effects of electronic prescribing on the quality of prescribing. Br J Clin Pharm; Online early article (July), doi: 10.1111/j.1365–2125.2007.02995.x
- 23.Beagon P, Scott M, McElnay J (2004) Quantifying the impact of an intensive clinical pharmacy service on readmission rates to hospital. Pharm World Sci 26:A9Google Scholar
- 24.Scullin C, Scott MG, Hogg A, McElnay JC (2007) An innovative approach to integrated medicines management. J Eval Clin Pract; online early release July 2007: doi: 10.1111/j.1365–2753.2006.00753.x
- 26.Jackson C, Owe P, Lea R (1993) Pharmacy discharge—a professional necessity for the 1990s. Pharm J 250:502–506Google Scholar
- 27.Delaney T (2007) Hospital pharmacy staffing and workload in Irish acute hospitals. IPJ 85(4):136–144Google Scholar
- 28.Health Service Executive. Transformation programme 2007–2010. http://www.hse.ie/en/Publications/TransformationProgramme2007–2010/FiletoUpload,4309,en.pdf. Accessed 30 Aug 2007