[Disagreement between physicians' medication records and information given by patients]

Area of Science:

• Medical Informatics
• Patient Safety
• Health Communication

Background:

• Discrepancies between patient-reported medication and family doctor records are common during hospitalisation.
• Evaluating these discrepancies is vital for ensuring patient safety and effective treatment.

Purpose of the Study:

• To assess the level of disagreement between family doctors' drug records and patient-reported information upon hospital admission.
• To determine the clinical relevance and potential dangers of these medication discrepancies.

Main Methods:

• A survey of 100 acutely admitted medical patients ingesting more than two non-over-the-counter (OTC) drugs.
• Cross-referencing patient medication interviews with family doctor records, including phone consultations when necessary.
• Blind analysis by senior and junior doctors to assess the clinical relevance of discrepancies.

Main Results:

• Clinically relevant and potentially dangerous discrepancies were identified in 40% of patients (95% CI 30%-50%).
• Overall medication list discrepancies were found in 63% of patients.
• No significant differences in age, sex, hospitalization method, or drug count were observed between patients with and without discrepancies.

Conclusions:

• There is an urgent need to enhance communication between primary and secondary healthcare sectors regarding patient medication.
• The high rate of medication record discrepancies highlights significant challenges in current healthcare coordination for patients with chronic diseases.