A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients’ medical recordsReport as inadecuate




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BMC Health Services Research

, 14:257

Quality, performance, safety and outcomes

Abstract

BackgroundAdverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm MRH, cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients’ medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision ICD-10 codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients.

MethodsClinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient’s medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as ‘explicit’ if unambiguous or ‘implicit’ if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded.

ResultsEighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present 855 of 1307 statements were identified; 65%, and usually explicit 705 of 855; 82%. The causative agent had the lowest proportion of explicit statements 139 of 201 statements were explicit; 69%. For two 3% discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six 9% had a MRH-related ICD-10 code.

ConclusionsAvailability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.

KeywordsHospital admissions UK Medical record Adverse drug reactions Medication errors Adherence AbbreviationsAandEAccident and emergency

ADRAdverse drug reaction

EDCElectronic discharge communication

GPGeneral Practitioner

ICDInternational Classification of Diseases

MRHMedication-related harm

NHSNational Health Service

PTWRPost-take ward round.

Electronic supplementary materialThe online version of this article doi:10.1186-1472-6963-14-257 contains supplementary material, which is available to authorized users.

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Author: Matthew Reynolds - Mary Hickson - Ann Jacklin - Bryony Dean Franklin

Source: https://link.springer.com/







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