Assessing Data Entry Accuracy of Medication Histories in Electronic Records by Student Pharmacists

Student pharmacists undertaking clinical integrated learning placements have been shown to play a valuable role in clinical settings, particularly in obtaining medication histories for hospitalized patients. Although electronic medical records (EMRs) are widely used in clinical practice, their integration into student pharmacist learning is limited. Currently, in South Australia, student pharmacists cannot independently access EMRs in clinical settings due to patient safety concerns; this limitation restricts their ability to contribute to patient care. This study aimed to assess the safety of student documentation of medication histories in an EMR.

A prospective study was conducted across 11 metropolitan tertiary hospitals in South Australia over 36 weeks. For each medication history, student pharmacists entered a medication list into the EMR, which the supervising pharmacist reviewed for potential discrepancies. The supervising pharmacist and an interprofessional consensus panel then assessed the potential harm of each error using the Harm Associated with Medication Error Classification system.

Student pharmacists entered 2262 medications, with 145 discrepancies identified over the course of the study. The most common discrepancy identified was incorrect directions (n = 65/145, 44.8%), followed by medication omission (n = 28/145, 19.3%). Most discrepancies were assessed as 'no harm' (n = 82/145, 56.6%) or 'minor harm' (n = 46/145, 31.7%), with only 1 instance classified as potential 'serious harm.'

Findings from this study provide valuable information that can inform decision-making on workflows, electronic system access, and supervision of student pharmacists that supports the delivery of efficient and quality patient care.