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A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients'
Matthew Reynolds1, Mary Hickson, Ann Jacklin
1Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust and UCL School of Pharmacy, Pharmacy Department, Ground Floor, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Matthew.reynolds@imperial.nhs.uk.
Background:
Adverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm (MRH), cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients' medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision (ICD-10) codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients.
Methods:
Clinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient's medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as 'explicit' if unambiguous or 'implicit' if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded.
Results:
Eighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present (855 of 1307 statements were identified; 65%), and usually explicit (705 of 855; 82%). The causative agent had the lowest proportion of explicit statements (139 of 201 statements were explicit; 69%). For two (3%) discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six (9%) had a MRH-related ICD-10 code.
Conclusions:
Availability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.
Insights
Medication-related harm (MRH) documentation in UK hospitals is often incomplete, especially regarding causative agents. International Classification of Disease 10th Revision (ICD-10) codes significantly underestimate the actual incidence of MRH.
Area of Science:
- Health Services Research
- Patient Safety
- Clinical Informatics
Background:
- Medication-related harm (MRH), encompassing adverse drug reactions, adherence issues, and errors, contributes significantly to UK hospital admissions (2.7-8.0%).
- Existing communication gaps between healthcare providers highlight a need to understand how MRH is documented in inpatient medical records.
- This study investigates the presence and quality of MRH documentation for patients admitted due to MRH at a London teaching hospital.
Purpose of the Study:
- To assess the completeness and clarity of MRH documentation within inpatient medical records.
- To evaluate the accuracy and utility of International Classification of Disease 10th Revision (ICD-10) codes in identifying MRH-related admissions.
Main Methods:
- Clinical pharmacists identified patients admitted for suspected MRH.
- Six data sources, including discharge summaries, were reviewed for MRH information (symptoms, diagnosis, causative agent, actions taken).
- Documentation was categorized as explicit or implicit; ICD-10 codes for confirmed MRH cases were recorded.
Main Results:
- Of 75 eligible patients, 65% had MRH documentation, predominantly explicit (82%).
- Documentation of the causative agent was least explicit (69%), with some cases missing from discharge summaries.
- Only 9% of patients with confirmed MRH had an appropriate ICD-10 code.
Conclusions:
- Improving the availability and explicitness of MRH information in medical records is crucial for better communication.
- Documenting reasons for medication changes can enhance care continuity.
- ICD-10 coding practices currently underestimate the true burden of MRH.
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