Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries

摘要

Background: Medication errors in hospital discharge summaries have the potential to cause serious harm to patients. These errors are generally associated with manual transcription of medications between medication charts and discharge summaries. Studies also show junior doctors are more likely to contribute to discharge medication error rates. Electronic discharge summaries have the potential to reduce discharge medication errors to ensure the safe handover of care to the primary care provider.rnObjectives: (1) Quantify and compare the medication transcription error rate from handwritten medications on manual discharge summaries to typed medications on electronic discharge summaries, and (2) examine the quality of medication documentation according to the level of medical training of the doctors who created the discharge summaries. Methods: A retrospective examination of 966 handwritten and 842 electronically generated discharge summaries was conducted in an Australian metropolitan hospital. The electronic discharge summaries at the study site were not integrated with an electronic medication management system and hence discharge medications were typed into the electronic discharge summary by the doctor. The discharge medication documentation in both types of summaries was transcribed, either handwritten or typed, from inpatient medication charts in paper-based medical records. Documentation differences between medications in discharge summaries and inpatient medication charts constituted medication errors. Results: 12.1% of handwritten and 13.3% of electronic summaries contained medication errors. The highest number of errors occurred with cardiovascular drugs. Medication omission was the commonest error. The confidence intervals of all odds ratios indicate handwritten and electronic summaries were similar for all areas of medication error. Error rates regarding all 13,566 individual medications for the 1808 summaries were similar by doctor medical training level (intern, resident, and registrar).rnConclusion: Similar medication error rates in handwritten and electronic summaries may be due to the common factor of transcription, either handwritten or typed, known to be associated with medication errors. Clinical information systems evolve and often in the early stages of implementation electronic discharge summaries are integrated with existing paper-based patient record systems. Automatic transfer of medications from an electronic medication management system to the electronic discharge summary holds the potential to reduce medication errors through the elimination of the transcription process.