Documenting For Safety: How Real-time Documentation Of Medication Changes Improve Physician-pharmacist Communication And Prevent Medication Errors At Discharge

• By: KIM, Woo-Youn (Seoul National University Bundang Hospital, South Korea)
• Co-author(s): Ms Woo-Youn Kim (Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Ms Anna Baek (Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Ms Yoonhee Kim (Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Ms Yewon Suh (Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea / College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea)
  Ms Eunsook Lee (Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Ju-Yeun Lee (College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea)
  Prof Euni Lee (College of Pharmacy and Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, South Korea)
  Prof Jong-chan Lee (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Hee Sun Park (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Eun Sun Kim (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Yejee Lim (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Nak-Hyun Kim (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Jung Hun Ohn (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Sun-wook Kim (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Jiwon Ryu (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  Prof Hye Won Kim (Division of General Internal Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea / Hospital Medicine Center, Seoul National University Bundang Hospital, Seongnam, South Korea)
  
• Abstract:

  Background: During the transition of care, timely and properly documenting medication changes is vital for ensuring medication safety. If a physician's intention to change a medication is not appropriately communicated to the nurse and pharmacist, breakdowns in communication can occur during medication preparation or administration, and the physician may also fail to record the change in the discharge summary.
  Purpose: We aimed to investigate the impact of real-time documenting in-hospital medication changes on documentation errors at discharge.
  Methods: We conducted a retrospective, observational cohort study in a tertiary hospital from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician’s intent of medication changes was clarified by free-text documentation in the electronic order entry system. We also conducted a pharmacists' survey for understanding the physician’s intent, communication and saving times of pharmacist’s work. By a documentation rate of medication changes of 100% and <100%, respectively, appropriately documented (AD) and inappropriately documented (ID) groups were defined. Any undocumented medication change at discharge was considered a ‘documentation error at discharge’. The factors associated with documentation errors at discharge were analyzed using multivariate logistic regression.
  Results: After reviewing 400 medication records with 1,201 episodes of medication discrepancies with or without free-text documentation in the electronic order entry, patients were categorized into AD (n=245, 61.3%) and ID (n=155, 38.8%) group. Documentation errors at discharge were significantly higher in the ID group than in the AD group (65.8% vs. 33.9%, p <0.001). Factors associated with documentation errors at discharge included belonging to the ID group, discharge from a non-hospitalist-managed ward rather than a hospitalist-managed ward, and having three or more intentional discrepancies. Favorable attitudes of pharmacist’s were observed toward physician’s real-time documenting of medication changes.
  Conclusion: Appropriate documentation of in-hospital medication changes facilitated by free-text communication significantly decreased documentation errors at discharge. This analysis underlines the importance of initiating medication reconciliation at the physician level when writing orders and highlights the role of communication between pharmacists and hospitalists in improving patient safety during the transition of care.
  Keywords: Human error, Medication reconciliation, Medication safety, Patient safety, Transitions in care, Hospital information systems, Hospital discharge, Quality audit