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An audit of medicines information quality in electronically generated discharge summaries – evidence to meet the Australian National Safety and Quality Health Service Standards
Author(s) -
Gilbert Alice V.,
Patel Bhavini K.,
Roberts Michael S.,
Williams Desmond B.,
Crofton Jackie H.,
Morris Nicola M.,
Wallace Joanna,
Gilbert Andrew L.
Publication year - 2017
Publication title -
journal of pharmacy practice and research
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 0.222
H-Index - 22
eISSN - 2055-2335
pISSN - 1445-937X
DOI - 10.1002/jppr.1256
Subject(s) - medicine , audit , accreditation , health care , patient safety , family medicine , quality management , medical emergency , quality (philosophy) , primary care , emergency medicine , service (business) , accounting , medical education , philosophy , economy , epistemology , economics , economic growth , business
Background Problems with achieving the continuum of medicines management are long‐standing. Audits are valuable in improving medication management and the quality and safety of healthcare systems. Aim To evaluate the accuracy and timeliness of electronic discharge summaries ( EDS ) provided to patients and their primary care providers at discharge. This was a forerunner to the study hospital's National Accreditation Examination and for routine safety and quality evaluation. Methods This study was a retrospective audit using an adaptation of the NSW indicator 5.3, ‘Percentage of discharge summaries that include medication therapy changes and explanations for changes’ ( National quality use of medicines indicators for Australian Hospitals . ACSQHC, Sydney, NSW, 2014). The additions to the NSW tool included: assessing the completion and timeliness of delivery to primary health care providers, and the accuracy of the information. Results In patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post‐discharge was also assessed. It indicated 46% accuracy, with the majority of errors being omissions of required medicines. None of the EDS s included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short‐term therapy, such as antibiotics, 71% of EDS s had documented a plan for short‐term therapies to be completed in the community. Conclusion The lack of information on the primary care provider recorded in the patient's clinical system and discharge summaries, limited the timely transfer of essential information on post‐discharge medicine management to the patient's primary care provider. Work has commenced on an educational program to improve data entry of the patient's primary care provider when they are admitted, and plans to improve compliance with the EDS policy.