Garcia Beate Hennie, Nguyen Michelle Thao, Småbrekke Lars, Skjold Frode, Aag Trine
Faculty of Health Sciences, UiT the Arctic University of Norway, Tromsoe, 9037, Norway.
Hospital Pharmacy of North Norway Trust, Postboks 6147, Langnes, Tromsø, 9291, Norway.
BMC Health Serv Res. 2025 May 1;25(1):634. doi: 10.1186/s12913-025-12669-x.
Hospital discharge summaries are crucial for transferring patient information to subsequent care providers, yet they often contain incomplete and incorrect medication details. This may lead to inappropriate medication therapy, medication-related problems and unnecessary patient harm. A 2014 study in Norway highlighted a low level of medication information completeness at a rural hospital. This study aimed to audit the completeness of medication information in discharge summaries from the same hospital and to identify factors that could improve medication safety in future efforts.
We randomly selected 240 discharge summaries from 2019 and applied seven national criteria defining the necessary medication information in discharge summaries; (1) reasons for changes in medication prescribing during hospitalization, (2) generic names, (3) administration forms, (4) dosage strengths, (5) dosage regimes stated, (6) indications for use and (7) the medication status categories new, changed, short course. A quantile regression model was applied to analyze factors associated with the medication information completeness in these summaries, adjusting for both patient- and hospital-related variables.
From 2550 assessed medications, information completeness in discharge summaries ranged from 0.0 to 1.0, with a mean of 0.904 (SD 0.15). The criteria with lowest information completeness were ´indication for use´ and ´reasons for changes in medication use stated at discharge´. A significant factor in enhancing completeness was the use of a digital tool for compiling the medication list, which increased the completeness coefficient by 0.23 to 0.83 when applied.
The completeness of medication information in discharge summaries from Helgelandssykehuset Mo i Rana was high and has significantly improved since 2014. The use of electronic tools for compiling medication lists notably enhances information completeness, while free-text lists should be avoided. This should be considered when developing future electronic medications management systems and tools to ensure quality of medication information.
医院出院小结对于将患者信息传递给后续护理提供者至关重要，但其中往往包含不完整和不正确的用药细节。这可能导致不适当的药物治疗、与药物相关的问题以及对患者不必要的伤害。2014年挪威的一项研究凸显了一家农村医院用药信息的完整性水平较低。本研究旨在审核同一家医院出院小结中用药信息的完整性，并确定在未来工作中可提高用药安全性的因素。
我们从2019年随机抽取了240份出院小结，并应用了七条定义出院小结中必要用药信息的国家标准；（1）住院期间用药处方变更的原因，（2）通用名，（3）剂型，（4）剂量强度，（5）规定的给药方案，（6）使用指征，以及（7）用药状态类别（新用药、用药变更、短期用药）。应用分位数回归模型分析这些小结中与用药信息完整性相关的因素，并对患者和医院相关变量进行调整。
在2550种评估药物中，出院小结中的信息完整性范围为0.0至1.0，平均为0.904（标准差0.15）。信息完整性最低的标准是“使用指征”和“出院时所述用药变更的原因”。提高完整性的一个重要因素是使用数字工具编制用药清单，应用该工具时完整性系数提高了0.23至0.83。
莫伊拉纳市海尔格兰医院出院小结中用药信息的完整性较高，自2014年以来有显著改善。使用电子工具编制用药清单显著提高了信息完整性，应避免使用自由文本清单。在开发未来的电子药物管理系统和工具时应考虑这一点，以确保用药信息的质量。
