Completeness of medication information in admission notes from emergency departments
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Completeness of medication information in admission notes from emergency departments. / Zahl-Holmstad, Birgitte; Garcia, Beate H.; Svendsen, Kristian; Johnsgård, Tine; Holis, Renata V.; Ofstad, Eirik H.; Risør, Torsten; Lehnbom, Elin C.; Wisløff, Torbjørn; Chan, Macty; Elenjord, Renate.
I: BMC Health Services Research, Bind 23, Nr. 1, 1425, 2023.Publikation: Bidrag til tidsskrift › Tidsskriftartikel › Forskning › fagfællebedømt
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TY - JOUR
T1 - Completeness of medication information in admission notes from emergency departments
AU - Zahl-Holmstad, Birgitte
AU - Garcia, Beate H.
AU - Svendsen, Kristian
AU - Johnsgård, Tine
AU - Holis, Renata V.
AU - Ofstad, Eirik H.
AU - Risør, Torsten
AU - Lehnbom, Elin C.
AU - Wisløff, Torbjørn
AU - Chan, Macty
AU - Elenjord, Renate
N1 - Publisher Copyright: © 2023, The Author(s).
PY - 2023
Y1 - 2023
N2 - 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.
AB - 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.
KW - Admission notes
KW - Electronic health records
KW - Hospital
KW - Medication information
KW - Medication systems
KW - Patient safety
KW - Quality of health care
U2 - 10.1186/s12913-023-10371-4
DO - 10.1186/s12913-023-10371-4
M3 - Journal article
C2 - 38104071
AN - SCOPUS:85179947815
VL - 23
JO - BMC Health Services Research
JF - BMC Health Services Research
SN - 1472-6963
IS - 1
M1 - 1425
ER -
ID: 378754617