Hammer Antje, Wagner Anke, Rieger Monika A, Manser Tanja
Institute for Patient Safety, University Hospital Bonn, Bonn, Germany
Institute of Occupational and Social Medicine and Health Services Research, University Hospital of Tübingen, Tuebingen, Germany.
BMJ Open. 2019 Nov 18;9(11):e034609. doi: 10.1136/bmjopen-2019-034609.
The medication process requires clear and transparent documentation in patient records. Incomplete or incorrect medication documentation may contribute to inappropriate clinical decision-making and adverse events. To comprehensively assess the quality of in-hospital medication documentation, we developed a retrospective chart review (RCR) instrument. We report on the development process, the feasibility of the instrument and describe our application of the instrument to a sample of patient records.
Cross-sectional study using an RCR instrument to evaluate paper-based, non-standardised prescription and medication administration charts (MediDocQ).
Two German university hospitals.
Records from 1361 patients admitted between April and July 2015 were evaluated.
The MediDocQ development process comprised six consecutive stages: focused literature review, web-based search, initial patient record screening, review by project advisory board, focus groups with professionals and pilot testing. The final 54-item RCR instrument covers three key components of medication documentation: (1) completeness of documented information (including prescription, medication administration and pro re nata (PRN) medication), (2) quality of transcriptions and (3) compliance with chart structure, legibility, handling of deletions and chart corrections. Descriptive statistics are presented as mean values, SD, median and interquartile ranges for individual items.
Overall, 33 out of 54 items resulted in mean values above 0.75, indicating high-quality medication documentation. Documentation quality was particularly compromised for verbal and PRN orders (which involve more steps than standard orders) and when documentation was not completed at the same time as medication administration.
MediDocQ is a patient safety instrument that can be used to evaluate the quality of medication documentation and identify components of the process where intervention is required. In our setting, standardisation of medication documentation, particularly regarding medication administration and PRN medication is a priority.
药物治疗过程需要在患者病历中有清晰且透明的记录。不完整或不正确的用药记录可能导致不恰当的临床决策和不良事件。为全面评估住院用药记录的质量，我们开发了一种回顾性病历审查（RCR）工具。我们报告该工具的开发过程、可行性，并描述我们将该工具应用于患者病历样本的情况。
采用RCR工具进行横断面研究，以评估纸质的、非标准化的处方和用药管理图表（MediDocQ）。
两家德国大学医院。
对2015年4月至7月期间收治的1361例患者的病历进行评估。
MediDocQ的开发过程包括六个连续阶段：重点文献回顾、基于网络的搜索、初步病历筛查、项目咨询委员会审查、专业人员焦点小组讨论和预试验。最终的54项RCR工具涵盖用药记录的三个关键组成部分：（1）记录信息的完整性（包括处方、用药管理和必要时用药（PRN）），（2）转录质量，以及（3）对图表结构的遵守情况、易读性、删除处理和图表更正。描述性统计以单个项目的平均值、标准差、中位数和四分位间距表示。
总体而言，54项中有33项的平均值高于0.75，表明用药记录质量较高。口头医嘱和PRN医嘱（比标准医嘱涉及更多步骤）以及用药记录与用药管理不同时完成时，记录质量尤其受到影响。
MediDocQ是一种患者安全工具，可用于评估用药记录的质量，并识别需要干预的过程组成部分。在我们的环境中，用药记录的标准化，特别是关于用药管理和PRN用药的标准化是优先事项。
