Accuracy and completeness of medication histories in patients in medical admission ward at University Teaching Hospital
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Quality documentation of medication histories at the time of hospital admission with regard to accuracy and completeness is not documented at UTH. A medication history is a detailed, accurate and complete account of all prescribed and non-prescribed medications that a patient had taken or is currently taking prior to a newly established or ambulatory care. This clinical research was guided by the question of how accurate and complete are medication histories are at the time of hospital admission. The aims were to determine the accuracy and completeness of documentation of medication histories in clinical records at the time of hospital admission. A cross-sectional study that involved interviewing patients and reviewing their clinical records at medical admission ward, UTH, was conducted over a period of 3 months. The study enrolled 322 patients admitted to this ward who were above 18 years of age and were able to communicate verbally, if not, were accompanied by a caregiver. Clinical records of these patients were screened to review all medications the patient was taking and patients/caregivers were interviewed to obtain a complete medication history. An interviewer administered questionnaire was used to collect data according to specific objectives. All information obtained through interviews was compared with medications recorded in the patient’s clinical records at the time of admission to the hospital. The Statistical Package for Social Sciences (SPSS) version 22 was used for all statistical calculations. Categorical data were expressed as frequency and percentage and presented using tables. The association between accuracy of medication histories and completeness of documentation was assessed using Pearson chi-square test, p<0.05 was considered statistically significant. Ethical approval was obtained from the ERES CONVERGE IRB Biomedical Research Ethics Committee. Of 287 clinical records, 175 (61%) incidents of inaccurate medication histories at the time of admission were identified and that medication histories in clinical records of patients were incomplete or poorly documented. This study shows that 61% of medication histories in patients at the time of admission to hospitals are inaccurate. Quality documentation of medication histories in clinical records at the time of hospital admission is poor.
The University of Zambia