Elliott Rohan A, Tan Yixin, Chan Vincent, Richardson Belinda, Tanner Francine, Dorevitch Michael I
Pharmacy Department, Austin Health, Heidelberg, VIC 3084, Australia.
Centre for Medicine Use and Safety, Monash University, Parkville, VIC 3052, Australia.
Pharmacy (Basel). 2019 Dec 30;8(1):2. doi: 10.3390/pharmacy8010002.
Inaccurate or missing medication information in medical discharge summaries is a widespread and intractable problem. This study evaluated the effectiveness and sustainability of an intervention in which ward-based hospital pharmacists reviewed, contributed and verified medication information in electronic discharge summaries (EDSs) in collaboration with physicians. Retrospective audits of randomly selected EDSs were conducted on seven wards at a major public hospital before and after implementation of the intervention and repeated two years later on four wards where the intervention was incorporated into usual pharmacist care. EDSs for 265 patients (prescribed a median of nine discharge medications) were assessed across the three time points. Pharmacists verified the EDSs for 47% patients in the first post-intervention audit and 68% patients in the second post-intervention audit. Following the intervention, the proportion of patients with one or more clinically significant discharge medication list discrepancy fell from 40/93 (43%) to 14/92 (15%), < 0.001. The proportion of clinically significant medication changes stated in the EDSs increased from 222/417 (53%) to 296/366 (81%), < 0.001, and the proportion both stated and explained increased from 206/417 (49%) to 245/366 (67%), < 0.001. Significant improvements were still evident after two years. Pharmacists spent a median of 5 (range 2-16) minutes per patient contributing to EDSs. Logistics, timing and pharmacist workload were barriers to delivering the intervention. Additional staff resources is needed to enable pharmacists to consistently deliver this effective intervention.
出院小结中用药信息不准确或缺失是一个普遍且棘手的问题。本研究评估了一项干预措施的有效性和可持续性，该干预措施是让病房药师与医生合作，对电子出院小结（EDS）中的用药信息进行审核、补充和核实。在一家大型公立医院的七个病房实施该干预措施前后，对随机抽取的EDS进行回顾性审核，并在两年后对四个将该干预措施纳入药师常规护理的病房再次进行审核。在三个时间点对265例患者（出院时开具的药物中位数为9种）的EDS进行了评估。在干预后的首次审核中，药师核实了47%患者的EDS，在第二次审核中为68%。干预后，有一项或多项具有临床意义的出院用药清单差异的患者比例从40/93（43%）降至14/92（15%），P<0.001。EDS中注明的具有临床意义的用药变更比例从222/417（53%）增至296/366（81%），P<0.001，且注明并解释的比例从206/417（49%）增至245/366（67%），P<0.001。两年后仍有显著改善。药师为每位患者的EDS提供补充信息的时间中位数为5分钟（范围2 - 16分钟）。后勤、时间安排和药师工作量是实施该干预措施的障碍。需要额外的人员资源，以使药师能够持续提供这种有效的干预措施。
