Taylor Simone, Welch Susan, Harding Andrew, Abbott Leonie, Riyat Baljit, Morrow Mel, Lawrence Dona, Rodda Sheridan, Heward Sarah
PharmD, GC CRM, Senior Pharmacist, Emergency Medicine and Research, Pharmacy Department, Austin Health, Heidelberg, VIC.
Aust Fam Physician. 2014 Oct;43(10):728.
Clinical handover and obtaining best possible medication histories (BPMH) at transition points in care are key patient safety pri-orities. This study aimed to determine the accuracy of medication histories documented on general practitioner (GP) referral letters for patients referred to emergency departments.
This was a multicentre prospective observational study in eight emergency departments. Patients taking ≥1 regular medication, referred to the emergency department with a GP letter and seen by a pharmacist were included. GP medication regimens were compared with BPMH documented by the emergency department pharmacist.
Of the GP letters (total 414), 361 (87%) had one or more discrepancies in the patients' regular medications and 62% had one or more regular medication discrepancies of moderate-high significance. Omission of medication was more prevalent in hand-written letters (P DISCUSSION: GP referral letters should not be used in isolation to determine the medication regimen taken before an emergency department presentation. Interventions are indicated to improve awareness and accuracy of medication documentation.
临床交接以及在护理转接点获取尽可能完善的用药史(BPMH)是患者安全的关键优先事项。本研究旨在确定转诊至急诊科患者的全科医生(GP)转诊信中记录的用药史的准确性。
这是一项在八个急诊科进行的多中心前瞻性观察性研究。纳入服用≥1种常规药物、持GP信转诊至急诊科并由药剂师诊治的患者。将GP的用药方案与急诊科药剂师记录的BPMH进行比较。
在GP信(共414封)中,361封(87%)在患者常规用药方面存在一处或多处差异,62%存在一处或多处具有中度至高度重要性的常规用药差异。手写信件中药物遗漏更为普遍(P 讨论:不应仅依靠GP转诊信来确定患者在急诊科就诊前服用的用药方案。需要采取干预措施来提高用药记录的意识和准确性。