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A medication reconciliation form and its impact on the medical record in a paediatric hospital
Pascal Bédard1, Lyne Tardif, Alexandre Ferland
1Department of Pharmacy, CHU Sainte-Justine, Montreal, Quebec, Canada.
Insights
Implementing a medication reconciliation form significantly improved the quality of medication information in pediatric patient charts upon discharge. This enhanced data accuracy is crucial for safe medication management.
Area of Science:
- Pediatric Healthcare
- Clinical Pharmacy
- Patient Safety
Background:
- Accurate medication information in patient charts is vital for safe and effective treatment.
- Gaps in medication data can lead to errors and adverse events.
- Medication reconciliation is a key process to ensure data accuracy.
Purpose of the Study:
- To assess the impact of a medication reconciliation form on the quality of medication information in pediatric medical charts.
- To compare medication data accuracy before and after form implementation.
- To evaluate the form's effectiveness at different stages of patient care (admission vs. discharge).
Main Methods:
- Retrospective chart review of pediatric patients (under 18) admitted to a hospital.
- Inclusion criteria: taking ≥2 home medications, >24-hour stay, discharged from specific wards.
- Data collection over two 20-week periods (pre- and post-implementation), reviewing 10 charts weekly.
- Quality assessment focused on dose, route, frequency (admission), and dose, route, frequency, duration (discharge).
Main Results:
- Analysis included 3275 medications (pre) and 3240 (post).
- No significant difference in medication information quality on admission (29.1% vs. 29.3%, P=0.86).
- Significant improvement in information quality on discharge post-implementation (51.7% vs. 65.2%, P<0.001).
Conclusions:
- Medication reconciliation forms, especially for discharge prescriptions, enhance the quality of drug-related information in medical records.
- Widespread adoption of these forms by healthcare professionals involved in prescribing is recommended.
- Improved medication data quality contributes to better patient safety and care coordination.
Objectives:
The objective of this study was to evaluate the quality of medication information available in medical charts before and after the implementation of a medication reconciliation form.
Patients And Methods:
This study is a retrospective chart review of patients under 18 years who were taking two medications or more at home and were admitted to a paediatric hospital for more than 24 hours and discharged from a general paediatrics, infectious disease, gastroenterology or pneumology ward over two 20-week periods (pre- and post-implementation). Each week, 10 medical records were randomly chosen and reviewed. The quality of the medication information was measured on admission (dose, route of administration and frequency) and on discharge (dose, route of administration, frequency and duration of treatment). The proportion of medications that fully met these criteria was compared between the groups using the chi-squared test.
Results:
Information was analysed for a total of 3275 medications in the pre-implementation group, vs. 3240 medications in the post-implementation group. Baseline characteristics were similar in both groups. On admission, the quality of medication information was comparable between the pre- and post-implementation groups (29.1 vs. 29.3%, respectively; P = 0.86). However, on discharge, an improvement in the quality of information was observed in the post-implementation group (51.7 vs. 65.2%; P < 0.001).
Conclusion:
Our study demonstrated that the forms used in the reconciliation process, in particular the discharge prescription, could increase the quality of the information related to drug use in medical charts. We believe that medication reconciliation forms should be widely used by all the health care professional teams involved in the drug history or prescription process.
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