Completeness of medication information in admission notes from emergency departmentsShow others and affiliations
2023 (English)In: BMC Health Services Research, E-ISSN 1472-6963, Vol. 23, no 1, article id 1425Article in journal (Refereed) Published
Abstract [en]
BackgroundMedication lists prepared in the emergency department (ED) form the basis for diagnosing and treating patients during hospitalization. Since incomplete medication information may lead to patient harm, it is crucial to obtain a correct and complete medication list at hospital admission. In this cross-sectional retrospective study we wanted to explore medication information completeness in admission notes from Norwegian EDs and investigate which factors were associated with level of completeness.MethodsMedication information was assessed for completeness by applying five evaluation criteria; generic name, formulation, dose, frequency, and indication for use. A medication completeness score in percent was calculated per medication, per admission note and per criterion. Quantile regression analysis was applied to investigate which variables were associated with medication information completeness.ResultsAdmission notes for patients admitted between October 2018 and September 2019 and using at least one medication were included. A total of 1,080 admission notes, containing 8,604 medication orders, were assessed. The individual medications had a mean medication completeness score of 88.1% (SD 16.4), while admission notes had a mean medication completeness score of 86.3% (SD 16.2). Over 90% of all individual medications had information about generic name, formulation, dose and frequency stated, while indication for use was only present in 60%. The use of an electronic tool to prepare medication information had a significantly strong positive association with completeness. Hospital visit within the last 30 days, the patient's living situation, number of medications in use, and which hospital the patient was admitted to, were also associated with information completeness.ConclusionsMedication information completeness in admission notes was high, but potential for improvement regarding documentation of indication for use was identified. Applying an electronic tool when preparing admission notes in EDs seems crucial to safeguard completeness of medication information.
Place, publisher, year, edition, pages
BioMed Central (BMC), 2023. Vol. 23, no 1, article id 1425
Keywords [en]
Patient safety, Quality of health care, Medication information, Admission notes, Electronic health records, Medication systems, Hospital
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health and Caring Sciences
Identifiers
URN: urn:nbn:se:lnu:diva-126772DOI: 10.1186/s12913-023-10371-4ISI: 001130386300003PubMedID: 38104071Scopus ID: 2-s2.0-85179947815OAI: oai:DiVA.org:lnu-126772DiVA, id: diva2:1828176
2024-01-162024-01-162024-02-15Bibliographically approved