Vawdrey David K, Chang Nancy, Compton Audrey, Tiase Vicky, Hripcsak George
Department of Biomedical Informatics, Columbia University, New York, NY.
AMIA Annu Symp Proc. 2010 Nov 13;2010:822-6.
Many hospitals have experienced challenges with accomplishing the Joint Commission's National Patient Safety Goal for medication reconciliation. Our institution implemented a fully electronic process for performing and documenting medication reconciliation at hospital admission. The process used a commercial EHR and relied on a longitudinal medication list called the "Outpatient Medication Profile" (OMP). Clinician compliance with documenting medication reconciliation was difficult to achieve, but approached 100% after a "hard-stop" reminder was implemented. We evaluated the impact of the process at a large urban academic medical center. Before the new process was adopted, the average number of medications contained in the OMP for a patient upon admission was <2. One year after adoption, the average number had increased to 4.7, and there were regular updates made to the list. Updating the OMP was predominantly done by physicians, NPs, and PAs (94%), followed by nurses (5%) and pharmacists (1%).
许多医院在实现联合委员会的药物重整全国患者安全目标方面都遇到了挑战。我们的机构实施了一个完全电子化的流程，用于在医院入院时进行药物重整并记录相关信息。该流程使用了一个商业电子健康记录系统，并依赖于一份名为“门诊用药档案”（OMP）的纵向用药清单。临床医生很难做到记录药物重整信息，但在实施“强制停止”提醒后，这一比例接近100%。我们在一家大型城市学术医疗中心评估了该流程的影响。在采用新流程之前，患者入院时OMP中包含的平均药物数量<2种。采用新流程一年后，平均数量增加到了4.7种，并且该清单会定期更新。OMP的更新主要由医生、执业护士和助理医师完成（94%），其次是护士（5%）和药剂师（1%）。
