A Comparative Study of the Conformity of the Documentation of Drug Doses Administered Pre and Post Implementation of an Electronic Medication Record

摘要

Background: There is a growing need for better documentation of drug doses in patient records, including higher traceability of steps performed by healthcare professionals. Electronic medication administration records (eMAR) are expected to increase the documentation of drug administration. Objectives: To compare the conformity of the documentation of drug doses administered pre-post implantation of an eMAR Methods: This retrospective pre-post study was conducted in a 45-bed pediatric surgery unit. The pre-implementation phase occurred between October 19~th-26~th, 2014. The post-implementaion phase occurred between May 3rd-14~th, 2015. Medication administration records were extracted from the digitalized patient healthcare record (Chartmax?). We compared the documented steps for each planned drug administration. A chi square test was used to compare conformity. We calculated the ratio of the number of steps documented on the number of steps that should be documented. Results: A total of 135 patient charts were consulted. A total 4157 doses (2551 pre-implementation, 1606 post-implementation) were included. They represented 543 regular drug orders (280 pre-implementation, 263 post-implementation), 388 as needed drug orders (260 pre-implementation, 128 post-implementation). Post-implementation, the conformity of the documentation of drug dose administered increased from 79.5% (689/867) to 88.1% (796/904) (p < 0.0001) for regular drug doses and from 16.3% (272/1665) to 43.5% (298/685) for as needed drug doses (p < 0.0001). The ratio of steps documented increased from 0.40 to 0.56 for regular drug doses and from 0.13 to 0.28 for as needed drug doses. However, for drug infusions (n= 19 doses pre-implementation, n= 17 doses post-implementation), it decreased from 0.63 to 0.51. Conclusions: This study showed an increase in conformity of the documentation of drug doses administered pre and post implementation of an eMAR. While eMAR can contribute to better documentation and traceability, further gain relies on human factor, enforcement of policy and procedures and periodical practice audits.