title: Summary adherence estimates do not portray the true incongruity between drug intake, nurse documentation and physicians' orders.
abstract: BACKGROUND
  Hemodialysis patients (HD) need to adhere to a complex medication regimen. Because their daily pill burden is one of the highest reported, poor compliance is a major cause of therapeutic failure. The primary aim of this study was to define patterns of medication prescription, intake and documentation among HD patients.
  
  
  METHODS
  HD patients treated between 2007 and 2009 and assigned to the largest health service provider in Israel were randomly selected. Drug practices were abstracted from their records and compared to electronic pharmacy data. The discrepancy between drug intake reports and the actual purchase was measured to estimate adherence. Drug purchase, intake report and physician order were plotted in complementing diagrams to appreciate consistency and discrepancy patterns.
  
  
  RESULTS
  The study included full analysis of 75 patients. The mean overall drug adherence was 56.7% (95% CI 53.6-59.9%), varying among drug families and over time. Often, there was a systematic disengagement between the nurses' documentation and the actual patient purchase. Specifically, we observed either different quantities of medication use, improper documentation of a non-purchased drug, drug purchase without nurse documentation and futile physician attempts to modify prescriptions of unpurchased medication. We found a high rate of physician order turbulence for active vitamin D and calcium.
  
  
  CONCLUSIONS
  Drug prescription, documentation and adherence are incongruent and their mismatches are diverse. Summary estimates do not divulge the extent of these disparities. These system-wide communication failures compromise patient care. Strategies to promote system reconciliation and reasonable medication prescription are in need.
authors.forename: Inbal
authors.initials: I
authors.lastname: Cohen-Glickman
authors.affiliation: Dialysis unit, Nephrology and Hypertension services, Hadassah-Hebrew University Medical Center, POB 12000, En Kerem campus, Jerusalem 91120, Israel. yhaviv@hadassah.org.il.
authors.forename: Yosef S
authors.initials: YS
authors.lastname: Haviv
authors.forename: Matan J
authors.initials: MJ
authors.lastname: Cohen
mesh_terms: D000284:Administration, Oral; D000368:Aged; D000928:Antidepressive Agents / Q000627:therapeutic use; D050071:Bone Density Conservation Agents / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000627:therapeutic use; D015897:Comorbidity; D004282:Documentation; D011307:Drug Prescriptions / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000706:statistics & numerical data; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007557:Israel; D007676:Kidney Failure, Chronic / Q000150:complications / Q000523:psychology / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009723:Nurse-Patient Relations; D009737:Nursing Records / Q000706:statistics & numerical data*; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data; D019338:Polypharmacy; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D006435:Renal Dialysis / Q000451:nursing*; D015203:Reproducibility of Results; D012494:Sampling Studies; D016903:Drug Monitoring
chemical_list: D000928:Antidepressive Agents; D050071:Bone Density Conservation Agents; D002317:Cardiovascular Agents; D007004:Hypoglycemic Agents