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01.12.2014 | Research article | Ausgabe 1/2014 Open Access

BMC Health Services Research 1/2014

A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients’ medical records

Zeitschrift:
BMC Health Services Research > Ausgabe 1/2014
Autoren:
Matthew Reynolds, Mary Hickson, Ann Jacklin, Bryony Dean Franklin
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1472-6963-14-257) contains supplementary material, which is available to authorized users.

Competing interests

All authors declare no competing interests.

Authors’ contributions

MR and BDF conceived the study. MR, BDF and MH participated in the study’s design. MR collected all data. All authors contributed to the interpretation of the results, and to drafting the final manuscript. All authors have read and approved the final manuscript.

Abstract

Background

Adverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm (MRH), cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients’ medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision (ICD-10) codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients.

Methods

Clinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient’s medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as ‘explicit’ if unambiguous or ‘implicit’ if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded.

Results

Eighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present (855 of 1307 statements were identified; 65%), and usually explicit (705 of 855; 82%). The causative agent had the lowest proportion of explicit statements (139 of 201 statements were explicit; 69%). For two (3%) discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six (9%) had a MRH-related ICD-10 code.

Conclusions

Availability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.
Zusatzmaterial
Additional file 2: Presence of implicit and explicit statements throughout the complete medical record. This table shows all results from each data source, and is referenced in the text as “Additional file 2”. Footnotes: *‘Cumulative availability’ was defined as the presence of a statement within the medical notes up and including the data source in question. In cases where explicit and implicit statements are present, only the explicit statement is counted in the numerator. #‘Cumulative opportunity to state’ is the total number of individual patients for whom at least one data source was examined up to and including that data source. (DOCX 20 KB)
Authors’ original file for figure 1
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Authors’ original file for figure 2
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Literatur
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