Leister K A, Edwards W A, Christensen D B, Clark H
Med Care. 1981 Jun;19(6):658-64. doi: 10.1097/00005650-198106000-00008.
This study sought to determine the completeness and congruence of records for drugs ordered and received by outpatients. The setting was a large outpatient medical facility that was part of a large multispecialty hospital. It was found that a listing of current drugs orders (prepared by physicians) and a listing of current prescription drugs consumed (prepared from pharmacy drug profiles) each agreed 73 per cent of the time with a list of 107 prescription drugs actually consumed by 26 study patients. Lists were compared based on drug name, strength and directions for use. Further, the physician and pharmacy lists correlated with one another 70 per cent of the time, indicating a substantial degree of inconsistent as well as incomplete drug records within the same setting. In another comparison involving medical chart drug notations and pharmacy drug profiles, a complete match or drug name, strength and directions for use occurred in 39 per cent of the cases, while a match on drug name only occurred 64 per cent of the time. The highest degree of congruence occurred between hospital discharge medication notes and outpatient drug profile records. Based on the results of this study, the common assumption that drug records in such settings are congruent and complete appears unwarranted.
本研究旨在确定门诊患者所订购和接收药物记录的完整性和一致性。研究地点是一家大型多专科医院下属的大型门诊医疗机构。研究发现,当前药物医嘱清单(由医生开具)和当前消耗的处方药清单(根据药房药物记录生成)与26名研究患者实际消耗的107种处方药清单的相符率均为73%。清单根据药物名称、规格和用法进行比较。此外,医生清单和药房清单的相互关联率为70%,这表明在同一环境中,药物记录存在相当程度的不一致以及不完整。在另一项涉及病历药物记录和药房药物记录的比较中,药物名称、规格和用法完全匹配的情况占39%,仅药物名称匹配的情况占64%。医院出院用药记录和门诊药物记录之间的一致性程度最高。基于本研究结果,认为此类环境中的药物记录是一致且完整的这一普遍假设似乎没有依据。