title: Insufficient medication documentation at hospital admission of cardiac patients: a challenge for medication reconciliation.
abstract: BACKGROUND
  Medication errors may occur when hospital doctors are not adequately informed about a patient's prescribed drugs.
  
  
  METHODS
  The drug lists of 103 patients who were electively admitted for coronary angiography were assessed. Discrepancies between lists noted in admission letters, patient's personal medication lists, and medication histories were analyzed.
  
  
  RESULTS
  Patients took a mean of 5 +/- 3 drugs. Nine percent of all drugs taken were only mentioned when a systematic medication history was obtained but were not stated in admission letters or on medication lists. Only 88% of admission letters reported the patient's medication. Twenty-one percent of generics were incorrectly documented as originals in the admission letter. Less than 50% of patients taking >or= 4 drugs had a written instruction on how to take their medication. A total of 86 drugs actually taken by the patients were not identical to those listed in the referral letter or the medication list, leaving uncertainties as to how outpatient medication should be continued. Medication was modified in 25% of all patients at hospital discharge.
  
  
  CONCLUSIONS
  Instructions for patients taking multiple drugs and information in admission letters need to be improved. These results underline the importance of medication reconciliation at hospital admission.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland. pascal.frei@usz.ch
authors.forename: Pascal
authors.initials: P
authors.lastname: Frei
authors.forename: Lars C
authors.initials: LC
authors.lastname: Huber
authors.forename: Roger W
authors.initials: RW
authors.lastname: Simon
authors.forename: Marco
authors.initials: M
authors.lastname: Bonani
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Lüscher
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D016507:Cardiology Service, Hospital; D002317:Cardiovascular Agents / Q000627:therapeutic use; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis; D004282:Documentation / Q000706:statistics & numerical data*; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008487:Medical History Taking; D008499:Medical Records; D008508:Medication Errors / Q000517:prevention & control*; D008875:Middle Aged; D010343:Patient Admission; D019338:Polypharmacy; D011446:Prospective Studies
chemical_list: D000925:Anticoagulants; D002317:Cardiovascular Agents; D007004:Hypoglycemic Agents; D000960:Hypolipidemic Agents