title: A descriptive exploratory study of how admissions caused by medication-related harm are documented within inpatients' medical records.
abstract: BACKGROUND
  Adverse drug reactions, poor patient adherence and errors, here collectively referred to as medication-related harm (MRH), cause around 2.7-8.0% of UK hospital admissions. Communication gaps between successive healthcare providers exist, but little is known about how MRH is recorded in inpatients' medical records. We describe the presence and quality of MRH documentation for patients admitted to a London teaching hospital due to MRH. Additionally, the international classification of disease 10th revision (ICD-10) codes attributed to confirmed MRH-related admissions were studied to explore appropriateness of their use to identify these patients.
  
  
  METHODS
  Clinical pharmacists working on an admissions ward in a UK hospital identified patients admitted due to suspected MRH. Six different data sources in each patient's medical record, including the discharge summary, were subsequently examined for MRH-related information. Each data source was examined for statements describing the MRH: symptom and diagnosis, identification of the causative agent, and a statement of the action taken or considered. Statements were categorised as 'explicit' if unambiguous or 'implicit' if open to interpretation. ICD-10 codes attributed to confirmed MRH cases were recorded.
  
  
  RESULTS
  Eighty-four patients were identified over 141 data collection days; 75 met our inclusion criteria. MRH documentation was generally present (855 of 1307 statements were identified; 65%), and usually explicit (705 of 855; 82%). The causative agent had the lowest proportion of explicit statements (139 of 201 statements were explicit; 69%). For two (3%) discharged patients, the causal agent was documented in their paper medical record but not on the discharge summary. Of 64 patients with a confirmed MRH diagnosis at discharge, only six (9%) had a MRH-related ICD-10 code.
  
  
  CONCLUSIONS
  Availability of information in the paper medical record needs improving and communication of MRH-related information could be enhanced by using explicit statements and documenting reasons for changing medications. ICD-10 codes underestimate the true occurrence of MRH.
authors.affiliation: Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust and UCL School of Pharmacy, Pharmacy Department, Ground Floor, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Matthew.reynolds@imperial.nhs.uk.
authors.forename: Matthew
authors.initials: M
authors.lastname: Reynolds
authors.forename: Mary
authors.initials: M
authors.lastname: Hickson
authors.forename: Ann
authors.initials: A
authors.lastname: Jacklin
authors.forename: Bryony Dean
authors.initials: BD
authors.lastname: Franklin
mesh_terms: D059019:Clinical Coding; D004282:Documentation / Q000592:standards; D064420:Drug-Related Side Effects and Adverse Reactions; D057286:Electronic Health Records; D006801:Humans; D008485:Medical Audit; D008508:Medication Errors / Q000009:adverse effects; D010343:Patient Admission; D011446:Prospective Studies; D006113:United Kingdom