Related Experiment Video
Updated: May 29, 2025
Multiplex Therapeutic Drug Monitoring by Isotope-dilution HPLC-MS/MS of Antibiotics in Critical Illnesses
Published on: August 30, 2018
Development and Validation of an Instrument to Assess Quality and Completeness of Medication-Related Discharge
Emma Bertilsson1, Victoria Östman1, Henrik Cam1
1Department of Pharmacy, Uppsala University, Uppsala, Sweden.
Rationale:
Transitions of care are periods of heightened risk of medication management errors. Poor-quality discharge documentation has been linked to incorrect or suboptimal medication use and unplanned hospital visits. Despite regulations defining essential components of medication-related discharge documentation, deficiencies persist, highlighting the need for a method to assess whether current clinical practice meets these standards.
Aims:
To conduct an initial validation of a newly developed instrument, the Complete Medication Documentation at Discharge - Measure (CMDD-M), assessing the quality and completeness of medication-related discharge documentation in a Swedish clinical setting.
Methods:
The instrument was developed and refined in multiple stages. In this study, two clinical pharmacists and one geriatrician independently applied the final instrument to discharge documentation from 50 patients. Inter-rater reliability (IRR) was evaluated using linear and quadratic weighted Cohen's κ (κW linear and κW quadratic).
Results:
The average CMDD-M score, based on the consensus of the three raters, was 3.40 (SD ± 2.50) out of nine possible points across the patients' discharge documentation. The IRR between the pharmacists' individual assessments demonstrated almost perfect agreement, with κW linear and κW quadratic values of 0.92 (95% CI: 0.80-1.00) and 0.97 (95% CI: 0.85-1.00), respectively. Moreover, the IRR between the pharmacists' consolidated score and the geriatrician's assessment displayed a moderate to strong agreement, with κW linear and κW quadratic values of 0.64 (95% CI: 0.48-0.80) and 0.80 (95% CI: 0.64-0.97), respectively.
Conclusion:
The CMDD-M demonstrated robust IRR confirming its ability to consistently and accurately measure the quality and completeness of medication-related discharge documentation in an easy-to-use form. Further research is recommended to ensure validity, generalisability and association with clinically relevant outcomes supporting the instrument's potential usefulness for evaluating and improving clinical practice and research.
More Related Videos
Related Concept Videos
01:31Discharge Summary Forms
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
01:29Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities
01:30Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:26Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
01:20Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
01:06Legal Guidelines for Documentation