Reynolds Matthew, Hickson Mary, Jacklin Ann, Franklin Bryony Dean
Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust and UCL School of Pharmacy, Pharmacy Department, Ground Floor, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
BMC Health Serv Res. 2014 Jun 16;14:257. doi: 10.1186/1472-6963-14-257.
Adverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm (MRH), cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients' medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision (ICD-10) codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients.
Clinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient's medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as 'explicit' if unambiguous or 'implicit' if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded.
Eighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present (855 of 1307 statements were identified; 65%), and usually explicit (705 of 855; 82%). The causative agent had the lowest proportion of explicit statements (139 of 201 statements were explicit; 69%). For two (3%) discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six (9%) had a MRH-related ICD-10 code.
Availability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.
药物不良反应、患者依从性差及用药错误，在此统称为药物相关伤害（MRH），导致英国约2.7 - 8.0%的住院病例。连续医疗服务提供者之间存在沟通差距，但对于住院患者病历中如何记录MRH知之甚少。我们描述了因MRH入住伦敦一家教学医院的患者的MRH记录情况及质量。此外，研究了归因于确诊的与MRH相关住院病例的国际疾病分类第10版（ICD - 10）编码，以探讨其用于识别这些患者的适用性。
英国一家医院住院病房的临床药师识别出因疑似MRH入院的患者。随后检查每位患者病历中的六个不同数据源，包括出院小结，以获取与MRH相关的信息。检查每个数据源中描述MRH的陈述：症状和诊断、致病因素的识别以及所采取或考虑的行动的陈述。如果陈述明确则分类为“明确”，如果可作多种解释则分类为“隐含”。记录归因于确诊的MRH病例的ICD - 10编码。
在141个数据收集日期间识别出84例患者；75例符合我们的纳入标准。MRH记录普遍存在（1307条陈述中有855条被识别；65%），且通常为明确陈述（855条中有705条；82%）。致病因素的明确陈述比例最低（201条陈述中有139条明确；69%）。对于两名（3%）出院患者，致病因素在纸质病历中有记录，但出院小结中未记录。在64例出院时确诊为MRH的患者中，只有6例（9%）有与MRH相关的ICD - 10编码。
纸质病历中的信息可用性需要改进，通过使用明确陈述和记录换药原因可以加强与MRH相关信息的沟通。ICD - 10编码低估了MRH的实际发生率。
