Completeness of medication information in admission notes from emergency departments
Abstract Background Medication 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 admi...
| Main Authors: | , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2023-12-01
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| Series: | BMC Health Services Research |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12913-023-10371-4 |
| _version_ | 1797388382444191744 |
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| author | Birgitte Zahl-Holmstad Beate H. Garcia Kristian Svendsen Tine Johnsgård Renata V. Holis Eirik H. Ofstad Torsten Risør Elin C. Lehnbom Torbjørn Wisløff Macty Chan Renate Elenjord |
| author_facet | Birgitte Zahl-Holmstad Beate H. Garcia Kristian Svendsen Tine Johnsgård Renata V. Holis Eirik H. Ofstad Torsten Risør Elin C. Lehnbom Torbjørn Wisløff Macty Chan Renate Elenjord |
| author_sort | Birgitte Zahl-Holmstad |
| collection | DOAJ |
| description | Abstract Background Medication 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. Methods Medication 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. Results Admission 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. Conclusions Medication 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. |
| first_indexed | 2024-03-08T22:40:01Z |
| format | Article |
| id | doaj.art-08fd08fb7cb44f1dae6f09e992bd8e6a |
| institution | Directory Open Access Journal |
| issn | 1472-6963 |
| language | English |
| last_indexed | 2024-03-08T22:40:01Z |
| publishDate | 2023-12-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Health Services Research |
| spelling | doaj.art-08fd08fb7cb44f1dae6f09e992bd8e6a2023-12-17T12:11:14ZengBMCBMC Health Services Research1472-69632023-12-0123111210.1186/s12913-023-10371-4Completeness of medication information in admission notes from emergency departmentsBirgitte Zahl-Holmstad0Beate H. Garcia1Kristian Svendsen2Tine Johnsgård3Renata V. Holis4Eirik H. Ofstad5Torsten Risør6Elin C. Lehnbom7Torbjørn Wisløff8Macty Chan9Renate Elenjord10Hospital Pharmacy of North Norway TrustHospital Pharmacy of North Norway TrustDepartment of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of NorwayHospital Pharmacy of North Norway TrustHospital Pharmacy of North Norway TrustDepartment of Medicine, Nordland Hospital TrustDepartment of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of NorwayDepartment of Pharmacy, Faculty of Health Sciences, UiT The Arctic University of NorwayHealth Services Research Unit, Akershus University HospitalHospital Pharmacy of North Norway TrustHospital Pharmacy of North Norway TrustAbstract Background Medication 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. Methods Medication 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. Results Admission 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. Conclusions Medication 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.https://doi.org/10.1186/s12913-023-10371-4Patient safetyQuality of health careMedication informationAdmission notesElectronic health recordsMedication systems |
| spellingShingle | Birgitte Zahl-Holmstad Beate H. Garcia Kristian Svendsen Tine Johnsgård Renata V. Holis Eirik H. Ofstad Torsten Risør Elin C. Lehnbom Torbjørn Wisløff Macty Chan Renate Elenjord Completeness of medication information in admission notes from emergency departments BMC Health Services Research Patient safety Quality of health care Medication information Admission notes Electronic health records Medication systems |
| title | Completeness of medication information in admission notes from emergency departments |
| title_full | Completeness of medication information in admission notes from emergency departments |
| title_fullStr | Completeness of medication information in admission notes from emergency departments |
| title_full_unstemmed | Completeness of medication information in admission notes from emergency departments |
| title_short | Completeness of medication information in admission notes from emergency departments |
| title_sort | completeness of medication information in admission notes from emergency departments |
| topic | Patient safety Quality of health care Medication information Admission notes Electronic health records Medication systems |
| url | https://doi.org/10.1186/s12913-023-10371-4 |
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