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PREPARING FOR VANESSA'S LAW:

机译:为维涅萨定律做准备:

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Background and Objective In the context of Vanessa’s Law, the medical records department and the pharmacy team of a mother-child hospital collaborated to create a system for coding adverse drug reactions (ADRs). This study was conducted to validate the coding of ADRs by the medical records team. Material and Methods This retrospective descriptive study covered 12 months of coding of hospitalization data by the medical records team (November 1, 2017, to October 31, 2018). The pharmacy team performed twice-monthly analysis to validate the ADR data, based on coded information for drugs and associated clinical manifestations. Results Over the 12-month study period, a total of 755 ADRs were coded by the medical records department (i.e., 2.1 ADRs per day, corresponding to 7.1% of admissions). For 34 (4.5%) of these ADRs the pharmacy team made a change to the code originally assigned by the medical records department. Eighty-five (11.5%) of the coded ADRs were deemed serious, as defined by Health Canada, but only 13 (15%) of these serious ADRs were reported to the regulatory authority. The new process allowed clinical manifestation codes to be associated with individual drugs in the pharmacy’s Med-Echo-Plus? software, which facilitated interpretation of the data. Following this study, coding practices were reviewed, a coding algorithm was developed, and the codes for 18 drugs were clarified. Conclusion This study highlights the feasibility of establishing a link between the medical records and pharmacy departments to validate the coding of ADRs. At the study hospital, this linkage has identified serious ADRs, for which reporting will soon be required by Health Canada.
机译:背景和目的在《凡妮莎法》的背景下,病历部门和母子医院的药房团队合作,共同创建了一个用于对药品不良反应(ADR)进行编码的系统。进行这项研究是为了验证病历团队对ADR的编码。资料和方法这项回顾性描述性研究涵盖了病历团队对住院数据编码的12个月(2017年11月1日至2018年10月31日)。药房团队根据药物和相关临床表现的编码信息,每月进行两次分析以验证ADR数据。结果在为期12个月的研究期内,病历部门总共对755种ADR进行了编码(即每天2.1种ADR,相当于入院人数的7.1%)。对于其中的34种(4.5%)ADR,药房团队对原由病历部门分配的代码进行了更改。根据加拿大卫生部的定义,八十五(11.5%)个已编码的ADR被认为是严重的,但只有13个(15%)这些严重的ADR被报告给监管机构。新程序允许将临床表现代码与药房的Med-Echo-Plus中的个别药物相关联。软件,它有助于解释数据。这项研究之后,对编码实践进行了回顾,开发了一种编码算法,并阐明了18种药物的编码。结论本研究突出了在病历和药房部门之间建立联系以验证ADR编码的可行性。在研究医院,这种联系确定了严重的ADR,加拿大卫生部很快将要求报告。

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