Transitions of care may result in medication errors, when information about a
patient’s medications is not communicated sufficiently. In this clinical record
review study, we aimed to evaluate the frequency of undocumented medication
discrepancies at discharge from hospital and evaluate which patient
characteristics could be associated with undocumented medication discrepancies.
Preadmission medication lists were compared against the medication list in the
discharge letters, taking into account medication changes documented in the
patient record throughout the inpatient stay and in the discharge summary. Out
of 200 patients, 174 (87%) were affected by at least one undocumented medication
discrepancy, mostly for regular medication. Of the 1972 medications used, 744
(38%) medications were changed without documentation in the patient record, the
majority being over-the-counter supplements and herbal medications. Polypharmacy
at admission and discharge was associated with increased undocumented medication
discrepancies. This study indicates a lack of medication reconciliation during
inpatient stay. Correct and complete medication lists at admission and discharge
may resolve many of these discrepancies, supporting patient safety at
transitions of care.
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