The discharge summary is a critically important form of communication when a patient is discharged from hospital. It has been shown in numerous studies that discharge summaries often lack sufficient information, with deficiencies in completeness and accuracy, and may not be received by the GP surgery before the patient’s first post-discharge contact. Poor quality medicines-related information can result in unintentional changes to the patient’s medication after discharge. Increasingly discharge summaries are being prepared and transmitted electronically; but research into the quality of medicines-related information in the electronic discharge summary was scant and not UK based.
To list and describe the content of medicines-related information in the electronic discharge summary, and evaluate the quality of information for completeness, accuracy and timeliness. To evaluate the quality of information about medication changes in the electronic discharge summary for completeness and accuracy.
Prospective content analysis of medicines-related information in a sample of the electronic discharge summaries generated over a two month period at a 400 bed general hospital. A stratified random sample of 10% of the electronic discharge summaries were further analysed to evaluate the quality of information about medication changes; by identifying if medication changes had occurred, and whether they were listed and the reasons for changes stated completely and accurately.
The majority of electronic discharge summaries were prepared by junior doctors, and in a timely manner in 97% of the sample of 1306 summaries. They contained medicines-related information categorised as allergies, discharge medications, and medication notes. Allergies data and discharge medication lists were complete and accurate in 96% and 89% of the summaries respectively; medication notes were written in 73%, most frequently about medication changes. Medication changes occurred, between admission and discharge, in 96% of cases; new medications were started (87%) more frequently than admission medications were changed (59%). Information about these medication changes were present in 69% of summaries, and were complete and accurate in 22% and 16% respectively. Complete and accurate information about all medication changes were shown in only 13% of summaries.
Electronic discharge summaries make an important contribution to patient safety in generating legible and timely information about allergies and discharge medications; but do not completely eliminate the risk of inaccurate or incomplete information. Documentation of information about medication changes in the electronic discharge summary was frequently incomplete or inaccurate. There was a gap between the need for, and provision of, information about medication changes in the discharge summary.
|Date of Award||Oct 2011|