Quality of medication information in discharge summaries from hospitals: an audit of electronic patient records

Abstract

Background: Low quality of medication information in discharge summaries from hospitals may jeopardize optimal therapy and put the patient at risk for medication errors and adverse drug events. <br> <p> Objective: To audit the quality of medication information in discharge summaries and explore factors associated with the quality. Setting Helgelandssykehuset Mo i Rana, a rural hospital in central Norway. <p> Method: For each month in 2013, we randomly selected 60 discharge summaries from the Department of Medicine and Surgery (totally 720) and evaluated the medication information using eight Norwegian quality criteria. <p>Main outcome measure: Mean score per discharge summary ranging from 0 (lowest quality) to 16 (highest quality). <p> Results: Mean score per discharge summary was 7.4 (SD 2.8; range 0–14), significantly higher when evaluating medications used regularly compared to mediations used as needed (7.80 vs. 6.52; p < 0.001). Lowest score was achieved for quality criteria concerning generic names, indications for medication use, reasons why changes had been made and information about the source for information. Factors associated with increased quality scores are increasing numbers of medications and male patients. Increasing age seemed to be associated with a reduced score, while type of department was not associated with the quality. <p> Conclusion: In discharge summaries from 2013, we identified a low quality of medication information in accordance with the Norwegian quality criteria. Actions for improvement are necessary and follow-up studies to monitor quality are needed.