Nassaralla Claudia L, Naessens James M, Chaudhry Rajeev, Hansen Melanie A, Scheitel Sidna M
The Division of Primary Care Internal Medicine, Medicine Clinic, Rochester, Minnesota, USA.
Qual Saf Health Care. 2007 Apr;16(2):90-4. doi: 10.1136/qshc.2006.021113.
To evaluate the causes of medication list inaccuracy, implement intervention to enhance overall accuracy of medication lists and measure the sustainability of the intervention.
A prospective study of patients seen in an academic, ambulatory primary care internal medicine clinic. Before the intervention, baseline data were analysed, assessing completeness of medication documentation in the electronic medical record. The intervention consisted of standardising the entire visit process from scheduling of the appointment to signing of the final clinical note by the physician. Each healthcare team member was instructed in her role to enhance accuracy of the documented medication list. Immediately after the intervention, a second data collection was undertaken to assess the effectiveness of the intervention on the accuracy of individual medications and medication lists. Finally, a year later, a third data collection was undertaken to assess the sustainability of the intervention.
Completeness of individual medications improved from 9.7% to 70.7% (p<0.001). However, completeness of the entire medication lists improved only from 7.7% to 18.5%. The incomplete documentation of medication lists was mostly due to lack of route (85.8%) and frequency (22.3%) for individual medications within a medication list. Also, documentation of over-the-counter and "as needed" medications was often incomplete. The incorrectness in a medication list was mostly due to misreporting of medications by patients or failure of clinicians to update the medication list when changes were made.
To improve the accuracy of medication lists, active participation of all members of the healthcare team and the patient is needed.
评估用药清单不准确的原因，实施干预措施以提高用药清单的整体准确性，并衡量干预措施的可持续性。
对一家学术性门诊初级保健内科诊所的患者进行前瞻性研究。在干预前，分析基线数据，评估电子病历中用药记录的完整性。干预措施包括规范从预约安排到医生签署最终临床记录的整个就诊流程。指导每个医疗团队成员履行其职责，以提高记录的用药清单的准确性。干预后立即进行第二次数据收集，以评估干预措施对个体药物和用药清单准确性的有效性。最后，在一年后进行第三次数据收集，以评估干预措施的可持续性。
个体药物的完整性从9.7%提高到70.7%（p<0.001）。然而，整个用药清单的完整性仅从7.7%提高到18.5%。用药清单记录不完整主要是由于用药清单中个体药物缺乏用药途径（85.8%）和用药频率（22.3%）。此外，非处方药和“按需”用药的记录往往不完整。用药清单中的错误主要是由于患者误报药物或临床医生在药物发生变化时未更新用药清单。
为提高用药清单的准确性，医疗团队的所有成员和患者都需要积极参与。
