Stanley William, Falconer Kate, Hume Megan
Emergency Medicine, Queensland Health, Rockhampton, AUS.
General Medicine, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR.
Cureus. 2025 May 20;17(5):e84445. doi: 10.7759/cureus.84445. eCollection 2025 May.
Introduction Medication reconciliation (MR) is a key patient safety process during hospital admission. MR ensures an accurate list of a patient's medications is compiled on hospital admission, enabling safe downstream prescribing and reducing adverse events. This responsibility falls primarily to the admitting clinician in paper-based systems with limited pharmacy input at the point of admission. This study aimed to assess local compliance with the national benchmarks and evaluate whether a structured audit-feedback intervention could improve MR documentation and the recording of reasons for withholding medications. Methods This quality improvement project was conducted over four 1-week periods: an initial audit, a pre-intervention baseline, a post-intervention follow-up, and a reaudit 10 days later. The medical records and prescription charts of 305 acute admissions were reviewed within 24 hours of presentation. The primary process measures were (i) the proportion of patients with a documented MR and (ii) the proportion of withheld medications with a documented reason, recorded in the clinical notes, drug chart, or MR sheet. The intervention included personalized compliance feedback to admitting doctors and consultants, public recognition of high performers, and educational posters placed in clinical areas. Two-proportion Z-tests were used to assess significance. Results The proportion of patients with a documented MR increased from 55 of 73 (75.3%) pre-intervention to 50 of 65 (89.3%) post-intervention (p = 0.044), and further to 64 of 69 (92.8%) at reaudit (p = 0.0049). The proportion of withheld medications with a documented reason rose from 23 of 39 (59.0%) to 30 of 37 (81.1%) post-intervention (p = 0.036) and remained elevated at 35 of 44 (79.6%) during the reaudit (p = 0.041). The most commonly withheld medication classes were diuretics (n = 27, 14.5%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (n = 24, 12.9%), and statins (n = 16, 8.6%). The most frequent reasons for withholding were acute kidney injury or dehydration (n = 39, 27.8%), hypotension (n = 15, 11.5%), and medications deemed not indicated (n = 15, 11.5%). Conclusion A targeted, low-cost audit-feedback intervention directed at admitting clinicians significantly improved compliance with MR standards and the documentation of withheld medications. These findings suggest that, even in resource-limited, paper-based settings, behavioral strategies can deliver meaningful improvements in prescribing safety and move practice closer to national standards.
引言
用药核对(MR)是住院期间保障患者安全的关键流程。MR可确保在患者入院时编制一份准确的用药清单,从而实现安全的后续开药并减少不良事件。在基于纸质记录的系统中,这一职责主要由收治临床医生承担,入院时药房的参与有限。本研究旨在评估本地对国家基准的遵守情况,并评估结构化的审核反馈干预措施是否能改善MR文件记录以及未用药原因的记录。
方法
本质量改进项目分四个为期1周的阶段进行:初始审核、干预前基线、干预后随访以及10天后的重新审核。在患者就诊后24小时内对305例急性入院患者的病历和处方进行审查。主要流程指标为:(i)有MR记录的患者比例;(ii)在临床记录、药物图表或MR表格中记录了未用药原因的未用药比例。干预措施包括向收治医生和会诊医生提供个性化的合规反馈、公开表彰表现出色者以及在临床区域张贴教育海报。采用双比例Z检验评估显著性。
结果
有MR记录的患者比例从干预前73例中的55例(75.3%)增至干预后的65例中的50例(89.3%)(p = 0.044),重新审核时进一步增至69例中的64例(92.8%)(p = 0.0049)。有记录原因的未用药比例从干预前39例中的23例(59.0%)升至干预后的37例中的30例(81.1%)(p = 0.036),重新审核期间保持在44例中的35例(7,9.6%)(p = 0.041)。最常停用的药物类别为利尿剂(n = 27,14.5%)、血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂(n = 24,12.9%)以及他汀类药物(n = 16,8.6%)。停用的最常见原因是急性肾损伤或脱水(n = 39,27.8%)、低血压(n = 15,11.5%)以及认为药物无指征(n = 15,11.5%)。
结论
针对收治临床医生的有针对性的低成本审核反馈干预措施显著提高了对MR标准的遵守情况以及未用药的文件记录。这些发现表明,即使在资源有限的纸质记录环境中,行为策略也能在开药安全性方面带来有意义的改善,并使实践更接近国家标准。