PDF(Pubmed)
Abstract：
UNASSIGNED: Transitional medication safety is crucial, as miscommunication about medication changes can lead to significant risks. Unclear or incomplete documentation during care transitions can result in outdated or incorrect medication lists at discharge, potentially causing medication errors, adverse drug events, and inadequate patient education. These issues are exacerbated by extended hospital stays and multiple care events, making accurate medication recall challenging at discharge.
UNASSIGNED: Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication.
UNASSIGNED: We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician\'s intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a \"documentation error at discharge\". Pharmacists\' survey was conducted to assess the impact of appropriate documentation on the pharmacists.
UNASSIGNED: After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician\'s documentation.
UNASSIGNED: Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.
During transitions of care, communication failures among healthcare professionals can lead to medication errors. Therefore, effective sharing of information is essential, especially when intentional changes in prescription orders are made. Documenting medication changes facilitates real-time communication, potentially improving medication reconciliation and reducing discrepancies. However, inadequate documentation of medication changes is common in clinical practice. This retrospective cohort study underlines the importance of real-time documentation of in-hospital medication changes. There was a significant reduction in documentation errors at discharge in fully documented group, where real-time documentation of medication changes was more prevalent. Pharmacists showed favorable attitudes toward the physician’s real-time documenting of medication changes because it provided valuable information on understanding the physician’s intent and improving communication and also saved time for pharmacists. This study concludes that physicians’ documentation on medication changes may reduce documentation errors at discharge, meaning that proper documentation of medication changes could enhance patient safety through effective communication.
UNASSIGNED: Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication.
UNASSIGNED: We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician\'s intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a \"documentation error at discharge\". Pharmacists\' survey was conducted to assess the impact of appropriate documentation on the pharmacists.
UNASSIGNED: After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician\'s documentation.
UNASSIGNED: Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.
During transitions of care, communication failures among healthcare professionals can lead to medication errors. Therefore, effective sharing of information is essential, especially when intentional changes in prescription orders are made. Documenting medication changes facilitates real-time communication, potentially improving medication reconciliation and reducing discrepancies. However, inadequate documentation of medication changes is common in clinical practice. This retrospective cohort study underlines the importance of real-time documentation of in-hospital medication changes. There was a significant reduction in documentation errors at discharge in fully documented group, where real-time documentation of medication changes was more prevalent. Pharmacists showed favorable attitudes toward the physician’s real-time documenting of medication changes because it provided valuable information on understanding the physician’s intent and improving communication and also saved time for pharmacists. This study concludes that physicians’ documentation on medication changes may reduce documentation errors at discharge, meaning that proper documentation of medication changes could enhance patient safety through effective communication.
摘要：
■过渡用药安全至关重要，因为关于药物变化的误解会导致重大风险。护理过渡期间不清楚或不完整的文档可能导致出院时的药物清单过时或不正确，可能导致用药错误，不良药物事件，患者教育不足。延长住院时间和多次护理事件加剧了这些问题，在出院时进行准确的药物召回具有挑战性。
■因此，我们旨在调查实时记录院内用药变化如何防止出院时无记录的用药变化,并改善医师与药剂师的沟通.
■我们在一家三级医院进行了一项回顾性队列研究。两名药剂师审查了2020年4月至6月入住急性医疗单位的患者的医疗记录。通过比较入院前和住院药物清单来确定住院药物差异，并验证医生的药物变更意图是否通过文件得到澄清。通过100%和<100%的药物变化记录率，分别,定义了完全记录(FD)和部分记录(PD)组.出院时任何未记录的药物变化都被认为是“出院时的文件错误”。进行药剂师调查以评估适当文件对药剂师的影响。
■查看400份用药记录后，患者分为FD组(61.3%)和PD组(38.8%).PD组出院时的记录错误明显高于FD组。与出院时文件错误相关的因素包括属于PD组，从非住院医师管理的病房出院，并且有三个或更多的故意差异。药剂师对医生的文件表现出良好的态度。
■医院内药物变化的适当文件，由自由文本通信促进，显着减少出院时的文件错误。该分析强调了药剂师和住院医师之间的沟通在改善护理过渡期间患者安全性方面的重要性。
在护理过渡期间，医疗保健专业人员之间的沟通失败可能导致用药错误。因此,有效的信息共享至关重要，特别是当处方订单有意改变时。记录药物变化有助于实时沟通，可能改善药物和解并减少差异。然而,在临床实践中，药物变化的记录不足是常见的。这项回顾性队列研究强调了实时记录住院药物变化的重要性。在完全记录在案的小组中，出院时的文件错误显着减少，在那里，实时记录药物变化更为普遍。药剂师对医生实时记录药物变化表现出良好的态度，因为它为了解医生的意图和改善沟通提供了有价值的信息，也为药剂师节省了时间。这项研究的结论是，医生关于药物变化的文档可以减少出院时的文档错误，这意味着正确记录药物变化可以通过有效的沟通提高患者的安全性。
■因此，我们旨在调查实时记录院内用药变化如何防止出院时无记录的用药变化,并改善医师与药剂师的沟通.
■我们在一家三级医院进行了一项回顾性队列研究。两名药剂师审查了2020年4月至6月入住急性医疗单位的患者的医疗记录。通过比较入院前和住院药物清单来确定住院药物差异，并验证医生的药物变更意图是否通过文件得到澄清。通过100%和<100%的药物变化记录率，分别,定义了完全记录(FD)和部分记录(PD)组.出院时任何未记录的药物变化都被认为是“出院时的文件错误”。进行药剂师调查以评估适当文件对药剂师的影响。
■查看400份用药记录后，患者分为FD组(61.3%)和PD组(38.8%).PD组出院时的记录错误明显高于FD组。与出院时文件错误相关的因素包括属于PD组，从非住院医师管理的病房出院，并且有三个或更多的故意差异。药剂师对医生的文件表现出良好的态度。
■医院内药物变化的适当文件，由自由文本通信促进，显着减少出院时的文件错误。该分析强调了药剂师和住院医师之间的沟通在改善护理过渡期间患者安全性方面的重要性。
在护理过渡期间，医疗保健专业人员之间的沟通失败可能导致用药错误。因此,有效的信息共享至关重要，特别是当处方订单有意改变时。记录药物变化有助于实时沟通，可能改善药物和解并减少差异。然而,在临床实践中，药物变化的记录不足是常见的。这项回顾性队列研究强调了实时记录住院药物变化的重要性。在完全记录在案的小组中，出院时的文件错误显着减少，在那里，实时记录药物变化更为普遍。药剂师对医生实时记录药物变化表现出良好的态度，因为它为了解医生的意图和改善沟通提供了有价值的信息，也为药剂师节省了时间。这项研究的结论是，医生关于药物变化的文档可以减少出院时的文档错误，这意味着正确记录药物变化可以通过有效的沟通提高患者的安全性。
