Abstract
Inaccurate or missing medication information in medical discharge summaries is a widespread and intractable problem. This study evaluated the effectiveness and sustainability of an intervention in which ward-based hospital pharmacists reviewed, contributed and verified medication information in electronic discharge summaries (EDSs) in collaboration with physicians. Retrospective audits of randomly selected EDSs were conducted on seven wards at a major public hospital before and after implementation of the intervention and repeated two years later on four wards where the intervention was incorporated into usual pharmacist care. EDSs for 265 patients (prescribed a median of nine discharge medications) were assessed across the three time points. Pharmacists verified the EDSs for 47% patients in the first post-intervention audit and 68% patients in the second post-intervention audit. Following the intervention, the proportion of patients with one or more clinically significant discharge medication list discrepancy fell from 40/93 (43%) to 14/92 (15%), p < 0.001. The proportion of clinically significant medication changes stated in the EDSs increased from 222/417 (53%) to 296/366 (81%), p < 0.001, and the proportion both stated and explained increased from 206/417 (49%) to 245/366 (67%), p < 0.001. Significant improvements were still evident after two years. Pharmacists spent a median of 5 (range 2–16) minutes per patient contributing to EDSs. Logistics, timing and pharmacist workload were barriers to delivering the intervention. Additional staff resources is needed to enable pharmacists to consistently deliver this effective intervention.
Highlights
Medical discharge summaries, or discharge letters, are a key communication tool for patient safety [1]
Failure to accurately communicate discharge medication information increases the risk of post-discharge prescribing errors, suboptimal monitoring of new medications, and unplanned re-hospitalisation [3,11,12,13,14]
Electronic discharge summaries (EDSs) have the potential to improve the accuracy of discharge summary data, especially if they are integrated with electronic prescribing systems, but studies comparing electronic discharge summaries (EDSs) with handwritten discharge summaries have produced variable results [17]
Summary
Discharge letters, are a key communication tool for patient safety [1]. Australian national indicators for quality use of medicines in hospitals state that all discharge summaries should include “a current, accurate and comprehensive list of medicines” and “medication therapy changes and explanations for changes” [2]. It is widely recognised, in Australia and internationally, that discharge summaries prepared by hospital physicians (including medical interns, junior medical officers and senior medical staff) often. Many strategies to improve the quality of medication information in discharge summaries have been trialed, including guidelines, performance indicators, physician education and discharge summary templates with specific sections for medication information [3,8,15]. We found that 59% of EDS had medication list discrepancies, and only 34% of clinically significant medication changes were explained [10]
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