Document Detail


Evaluation of medication list completeness, safety, and annotations.
MedLine Citation:
PMID:  22195166     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
Clinical documents frequently contain a list of a patient's medications. Missing information about the dosage, route, or frequency of a medication impairs clinical communication and may harm patients. We examined 253 medication lists. There were 181 lists (72%) with at least one medication missing a dose, route, or frequency. Missing information was judged to be potentially harmful in 47 of the lists (19% of 253) by three physician reviewers (kappa=0.69). We also observed that many lists contained additional information included as annotations, prompting a secondary thematic analysis of the annotations. Fifty-five of the 253 lists (22%) contained one or more annotations. The most frequent types of annotations were comments about the patient's medical history, the clinician's treatment plan changes, and the patient's adherence to a medication. Future development of electronic medication reconciliation tools to improve medication list completeness should also support annotating the medication list in a flexible manner.
Authors:
Michael C Owen; Nancy M Chang; David H Chong; David K Vawdrey
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Publication Detail:
Type:  Journal Article     Date:  2011-10-22
Journal Detail:
Title:  AMIA ... Annual Symposium proceedings / AMIA Symposium. AMIA Symposium     Volume:  2011     ISSN:  1942-597X     ISO Abbreviation:  AMIA Annu Symp Proc     Publication Date:  2011  
Date Detail:
Created Date:  2011-12-23     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101209213     Medline TA:  AMIA Annu Symp Proc     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1055-61     Citation Subset:  IM    
Affiliation:
Columbia University, New York, NY.
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