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首页> 外文期刊>The Canadian journal of hospital pharmacy. >Completeness of Medication Reconciliation Performed by Pediatric Resident Physicians at Hospital Admission for Asthma
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Completeness of Medication Reconciliation Performed by Pediatric Resident Physicians at Hospital Admission for Asthma

机译：儿科居民医师在医院入院哮喘入院的完整性

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Background: Medication errors at hospital admission, though preventable, continue to be common. The process of medication reconciliation has been identified as an important tool in reducing medication errors. The first step in medication reconciliation involves documenting a patient’s best possible medication history (BPMH); at the authors’ tertiary pediatric hospital, this step is completed at time of admission by resident physicians. Objectives: To describe and quantify the completeness of admission BPMH by resident physicians for pediatric inpatients with asthma. Methods: This single-centre, retrospective chart review evaluated documentation of admission medication reconciliation for pediatric inpatients with asthma who were admitted between January 2016 and December 2017. Medication reconciliation forms were deemed incomplete if records for asthma medications were missing drug name, inhaler strength or oral drug dose, directions for use, or evidence of reconciliation. Results: A total of 241 charts were evaluated, of which 97 (40%) had incomplete documentation for at least 1 medication; in particular, 48 (37%) of the 130 inhaled corticosteroid orders were missing inhaler strength. For most of the charts with incomplete medication history (68% [66/97]), no reason was documented; however, review of the medication reconciliation forms and physician notes revealed that families might have been unsure of a patient’s home medications or physicians might have left it to the pharmacy to clarify medication doses. Conclusions: Documentation of inhaler medications on admission medication reconciliation forms completed by resident physicians for pediatric patients with asthma was often incomplete. Future quality improvement interventions, including resident and patient education, are required at the study institution. Collaboration with pharmacy services is also likely to improve completeness of the medication reconciliation process.
机译：背景：入院时的药物错误虽然可以预防，但仍然很常见。药物调节过程已被确定为减少药物错误的重要工具。药物调节的第一步是记录患者的最佳用药史（BPMH）；在作者所在的三级儿科医院，这一步骤在住院医师入院时完成。目的：描述和量化住院医师对哮喘患儿住院BPMH的完整性。方法：这项单中心回顾性图表审查评估了2016年1月至2017年12月住院的哮喘儿童住院患者的入院药物调节记录。如果哮喘药物记录中缺少药物名称、吸入器强度或口服药物剂量、使用说明或对账证据，则认为药物对账表不完整。结果：共评估了241张图表，其中97张（40%）至少有1种药物的记录不完整；特别是，130份吸入皮质激素订单中有48份（37%）缺少吸入器强度。对于大多数有不完整用药史的图表（68%[66/97]），没有记录任何原因；然而，对药物调节表和医生记录的审查显示，家属可能不确定患者的家庭药物，或者医生可能将其留给药房澄清药物剂量。结论：住院医师为哮喘患儿填写的入院药物调节表中的吸入器药物记录往往不完整。研究机构需要未来的质量改善干预措施，包括住院医师和患者教育。与药房服务部门的合作也有可能提高药物调节过程的完整性。

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