Assessing the Accuracy and Quality of Medication History Collection: Effect of Implementation of Electronic Health Record [abstract]

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Abstract from 2013 ACCP Annual Meeting:

PURPOSE: We hypothesized that pharmacy staff auditing of previously recorded admission medication histories will identify significant and potential medication errors, and that implementation of an electronic medical record [EMR] will not improve the quantity of discrepancies or the quality of admission medication histories, despite showing Joint Commission and Heart Failure Core Measure compliance.

METHODS: At our institution, medication reconciliation is completed at the time of admission through collaboration with prescribers and nursing staff. A pharmacy medication reconciliation team is utilized on the cardiac step down unit and employs pharmacy technicians to obtain an accurate and complete medication history. This history is verified by a pharmacist, compared to the initial medication history and inpatient medication orders. Identified discrepancies are reconciled with a licensed prescriber. A retrospective evaluation assessed the discrepancies identified by the pharmacy team medication history audits, as well as audits completed by clinical pharmacists on other hospital units, and compared the quantity of discrepancies before and after EMR implementation.

RESULTS: With support provided by the pharmacy team, medication reconciliation completion was 82% pre-EMR implementation and increased to 91% immediately post-EMR implementation; Core Measure compliance has remained above 90%. The average number of medication omissions per patient upon admission medication reconciliation was 0.55 pre-EMR implementation and increased to 2.32 post-EMR implementation. The average number of incorrect drugs/patient upon admission medication reconciliation 0.16 (pre) and 0.61 (post); and incorrect doses/patient was 0.32 (pre) and increased to 0.63 (post).

CONCLUSION: Despite showing medication reconciliation and core measure compliance with the implementation of EMR, our data shows discrepancies between the medication lists collected as a routine part of admission and those lists collected via the pharmacy team audit. In fact, more errors were identified after EMR implementation. The pharmacy team’s activities should be continued and even expanded in order to prevent future discrepancies.


Version of record can be found through Wiley.