Medication information completeness in discharge summaries from a Norwegian rural hospital - a cross-sectional study.

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.