Quality of medication information in discharge summaries from hospitals: an audit of electronic patient records
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Background Low quality of medication information in discharge summaries from hospitals may jeopardize optimal therapy and put the patient at risk for medication errors and adverse drug events. Objective To audit the quality of medication information in discharge summaries and explore factors associated with the quality. Setting Helgelandssykehuset Mo i Rana, a rural hospital in central Norway. Method For each month in 2013, we randomly selected 60 discharge summaries from the Department of Medicine and Surgery (totally 720) and evaluated the medication information using eight Norwegian quality criteria. Main outcome measure Mean score per discharge summary ranging from 0 (lowest quality) to 16 (highest quality). Results Mean score per discharge summary was 7.4 (SD 2.8; range 0–14), significantly higher when evaluating medications used regularly compared to mediations used as needed (7.80 vs. 6.52; p < 0.001). Lowest score was achieved for quality criteria concerning generic names, indications for medication use, reasons why changes had been made and information about the source for information. Factors associated with increased quality scores are increasing numbers of medications and male patients. Increasing age seemed to be associated with a reduced score, while type of department was not associated with the quality. Conclusion In discharge summaries from 2013, we identified a low quality of medication information in accordance with the Norwegian quality criteria. Actions for improvement are necessary and follow-up studies to monitor quality are needed.
KeywordsClinical audit Communication Hospital Medication Systems Norway Patient discharge summary Quality of health care
This study has been performed as a master study in pharmacy. We are grateful to all staff at Helgelandssykehuset Mo i Rana, Hospital Pharmacy of North Norway Trust and UiT the Arctic University of Norway that have contributed to carrying out this study, both by identification of discharge summaries, data extraction and professional discussions.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Conflicts of interest
The authors declared that they have no conflict of interest.
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