Completeness and accuracy of adverse drug reaction documentation in electronic medical records at a tertiary care hospital in Australia.

Gina McLachlan, Airley Broomfield, Rohan Elliott
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引用次数: 3

Abstract

Background: A large proportion of patients presenting to hospitals have experienced a previous adverse drug reaction (ADR). Electronic medical records (EMRs) present an opportunity to accurately document ADRs and alert clinicians against inadvertent rechallenge where there is a pre-existing reaction. However, EMR systems are imperfect and rely on the accuracy of the data entered. Objective: To ascertain the completeness of ADR documentation and the accuracy of the classification of ADRs as allergy versus intolerance in the EMR at a major metropolitan hospital in Australia. Method: Cross-sectional audit of the ADR field of the EMR for a sample of patients on four different wards over 3 weeks to ascertain the completeness of ADR documentation and the accuracy of classification of ADRs. Results: Of the 264 patients assessed, 102 (38.6%) had a total of 210 ADRs documented in the EMR. Of these, 105 (50%) were considered to have complete documentation; 63/210 (30.0%) were missing a reaction description and 88/210 (41.9%) were missing severity information. For those ADRs with a reaction description (n = 147), 97 (66.0%) were considered to be appropriately classified as allergy or intolerance. Conclusion: Incomplete and inaccurate ADR documentation was common. These findings highlight a need for optimising ADR documentation to improve appropriate medication use in hospital. Implications: Improved EMR design and education of healthcare workers on the importance of complete and accurate documentation of reactions are needed to improve completeness and accuracy of ADR classification.

澳大利亚一家三级医院电子病历中药物不良反应记录的完整性和准确性。
背景:到医院就诊的患者中有很大一部分曾发生过药物不良反应(ADR)。电子医疗记录(emr)提供了一个准确记录不良反应的机会,并提醒临床医生在存在预先存在的反应时不要无意中再次提出质疑。然而,电子病历系统是不完善的,依赖于输入数据的准确性。目的:了解澳大利亚某大城市医院病历中ADR记录的完整性和ADR分类为过敏与不耐受的准确性。方法:对4个不同病房样本患者3周内EMR的ADR字段进行横断面审计,以确定ADR记录的完整性和ADR分类的准确性。结果:在评估的264例患者中,102例(38.6%)在EMR中记录了总计210例adr。其中,105例(50%)被认为具有完整的文件;63/210(30.0%)缺失反应描述,88/210(41.9%)缺失严重程度信息。在有反应描述的adr (n = 147)中,97例(66.0%)被认为属于过敏或不耐受。结论:ADR记录不完整、不准确是常见的。这些发现强调需要优化不良反应文件,以提高医院药物的适当使用。结论:需要改进电子病历设计,并教育医护人员完整准确记录反应的重要性,以提高ADR分类的完整性和准确性。
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