An audit of the accuracy of medication information in electronic medical discharge summaries linked to an electronic prescribing system

Abstract

Background: Poor communication of medication information to general practitioners when patients are discharged from hospital is a widely recognised problem. There has been little research exploring the accuracy of medication information in electronic discharge summaries (EDS) linked to hospital e-prescribing systems. Objective: To evaluate the accuracy of medication lists and medication change information in EDS produced using an integrated e-prescribing and EDS system (where EDS discharge medication lists were imported from discharge e-prescription records, medication change information was manually entered, and medications were dispensed from paper copies of the patients' e-prescriptions). Method: Retrospective audit of EDSs for a random sample, representative of adult patients ( n = 87) discharged from a major teaching hospital. EDS medication lists were compared to pharmacist-verified paper discharge prescriptions (considered to be the most accurate discharge medication list) to identify discrepancies. EDS medication change information was compared to medication changes identified by comparing pharmacist-verified “Medication History on Admission” forms with pharmacist-verified paper discharge prescriptions. Results: There were 85/87 (98%) EDSs that included a discharge medication list. Of these, 50/85 (59%) contained one or more medication list discrepancies (median 1, range 0–15). The most common discrepancy was omission of medication (58%); 84/131 (64%) discrepancies were considered clinically significant (risk of adverse outcome); 162/351 (46%) clinically significant medication changes were stated in the EDS; and 153/351 (44%) changes were both stated and included a reason. Conclusion: EDS discrepancies were common despite integration with e-prescribing. Eliminating paper prescriptions, enhancing e-prescribing/EDS functionality and involving pharmacists in EDS preparation may reduce discrepancies.