Wagner M M, Hogan W R
Section of Medical Informatics, University of Pittsburgh School of Medicine, PA, USA.
J Am Med Inform Assoc. 1996 May-Jun;3(3):234-44. doi: 10.1136/jamia.1996.96310637.
To measure the accuracy of medication records stored in the electronic medical record (EMR) of an outpatient geriatric center. The authors analyzed accuracy from the perspective of a clinician using the data and the perspective of a computer-based medical decision-support system (MDSS).
Prospective cohort study.
The EMR at the geriatric center captures medication data both directly from clinicians and indirectly using encounter forms and data-entry clerks. During a scheduled office visit for medical care, the treating clinician determined whether the medication records for the patient were an accurate representation of the medications that the patient was actually taking. Using the available sources of information (the patient, the patient's vials, any caregivers, and the medical chart), the clinician determined whether the recorded data were correct, whether any data were missing, and the type and cause for each discrepancy found.
At the geriatric center, 83% of medication records represented correctly the compound. dose, and schedule of a current medication; 91% represented correctly the compound. 0.37 current medications were missing per patient. The principal cause of errors was the patient (36.1% of errors), who misreported a medication at a previous visit or changed (stopped, started, or dose-adjusted) a medication between visits. The second most frequent cause of errors was failure to capture changes to medications made by outside clinicians, accounting for 25.9% of errors. Transcription errors were a relatively ucommon cause (8.2% of errors). When the accuracy of records from the center was analyzed from the perspective of a MDSS, 90% were correct for compound identity and 1.38 medications were missing or uncoded per patient. The cause of the additional errors of omission was a free-text "comments" field-which it is assumed would be unreadable by current MDSS applications-that was used by clinicians in 18% of records to record the identity of the medication.
Medication records in an outpatient EMR may have significant levels of data error. Based on an analysis of correctable causes of error, the authors conclude that the most effective extension to the EMR studied would be to expand its scope to include all clinicians who can potentially change medications. Even with EMR extensions, however, ineradicable error due to patients and data entry will remain. Several implications of ineradicable error for MDSSs are discussed. The provision of a free-text "comments" field increased the accuracy of medication lists for clinician users at the expense of accuracy for a MDSS.
评估一家老年门诊中心电子病历（EMR）中存储的用药记录的准确性。作者从使用这些数据的临床医生视角以及基于计算机的医疗决策支持系统（MDSS）视角分析了准确性。
前瞻性队列研究。
老年中心的电子病历通过两种方式获取用药数据，一是直接从临床医生处获取，二是通过会诊表格和数据录入员间接获取。在一次预定的医疗门诊就诊期间，主治临床医生确定患者的用药记录是否准确反映了患者实际服用的药物。临床医生利用现有的信息来源（患者、患者的药瓶、任何护理人员以及病历），确定记录的数据是否正确、是否有任何数据缺失，以及发现的每一处差异的类型和原因。
在老年中心，83%的用药记录正确反映了当前药物的成分、剂量和用药时间表；91%正确反映了药物成分。每位患者平均有0.37种当前用药记录缺失。错误的主要原因是患者（占错误的36.1%），患者在之前的就诊中误报用药情况，或者在两次就诊之间更改（停用、开始服用或调整剂量）了药物。错误的第二大常见原因是未能获取外部临床医生所做的用药更改，占错误的25.9%。转录错误是相对较少见的原因（占错误的8.2%）。当从MDSS的视角分析该中心记录的准确性时，90%的药物成分记录正确，每位患者有1.38种用药记录缺失或未编码。额外遗漏错误的原因是一个自由文本“注释”字段——据推测当前的MDSS应用程序无法读取该字段——18%的记录中临床医生用它来记录药物的名称。
门诊电子病历中的用药记录可能存在大量数据错误。基于对可纠正错误原因的分析，作者得出结论，对于所研究的电子病历，最有效的扩展是扩大其范围，将所有可能更改用药的临床医生纳入其中。然而，即便扩展了电子病历，由于患者和数据录入导致的无法根除的错误仍会存在。讨论了无法根除的错误对MDSS的若干影响。提供自由文本“注释”字段提高了临床医生用户用药清单的准确性，但牺牲了MDSS的准确性。
