Poor drug history documentation in admission medical notes: clerking prompts and junior doctor education alone do not significantly reduce errors

Poor drug history documentation on admission may lead to medication errors; a leading cause of avoidable harm.

To assess the quality of drug histories in the notes of patients admitted to an emergency assessment unit and impact of interventions to improve documentation.

Data were collected on the accuracy of documentation in 281 drug histories including errors of omission, frequency and dose.

The mean error rate was high at more than five per drug history. Omitted drugs included warfarin and long-term steroids, the consequences of which were potentially serious. Clerking prompts and education alone did not improve errors significantly.

The error rate in drug histories is unacceptably high. More research is needed to explore factors involved in such documentation errors.