title: Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore.
abstract: BACKGROUND
  Medication discrepancies and poor documentation of medication changes (e.g. lack of justification for medication change) in physician discharge summaries can lead to preventable medication errors and adverse outcomes. This study aimed to identify and characterise discrepancies between preadmission and discharge medication lists, to identify associated risk factors, and in cases of intentional medication discrepancies, to determine the adequacy of the physician discharge summaries in documenting reasons for the changes.
  
  
  METHODS
  A retrospective clinical record review of 150 consecutive elderly patients was done to estimate the number of medication discrepancies between preadmission and discharge medication lists. The two lists were compared for discrepancies (addition, omission or duplication of medications, and/or a change in dosage, frequency or formulation of medication). The patients' clinical records and physician discharge summaries were reviewed to determine whether the discrepancies found were intentional or unintentional. Physician discharge summaries were reviewed to determine if the physicians endorsed and documented reasons for all intentional medication changes.
  
  
  RESULTS
  A total of 279 medication discrepancies were identified, of which 42 were unintentional medication discrepancies (35 were related to omission/addition of a medication and seven were related to a change in medication dosage/frequency) and 237 were documented intentional discrepancies. Omission of the baseline medication was the most common unintentional discrepancy. No reasons were provided in the physician discharge summaries for 54 (22.8%) of the intentional discrepancies.
  
  
  CONCLUSIONS
  Unintentional medication discrepancies are a common occurrence at hospital discharge. Physician discharge summaries often do not have adequate information on the reasons for medication changes.
authors.affiliation: University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Farooq
authors.initials: F
authors.lastname: Akram
authors.affiliation: Waikato District Health Board, Hamilton, New Zealand.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Huggan
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Valencia
authors.initials: V
authors.lastname: Lim
authors.affiliation: Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Yufang
authors.initials: Y
authors.lastname: Huang
authors.affiliation: Duke-NUS Graduate Medical School, Centre for Quantitative Medicine, Singapore ; Singapore Clinical Research Institute, Singapore.
authors.forename: Fahad Javaid
authors.initials: FJ
authors.lastname: Siddiqui
authors.affiliation: Duke-NUS Graduate Medical School, Centre for Quantitative Medicine, Singapore ; Singapore Clinical Research Institute, Singapore.
authors.forename: Pryseley Nkouibert
authors.initials: PN
authors.lastname: Assam
authors.affiliation: University Medicine Cluster, National University Health System, Singapore ; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
authors.forename: Reshma A
authors.initials: RA
authors.lastname: Merchant
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D059065:Medication Reconciliation / Q000706:statistics & numerical data*; D010343:Patient Admission; D010351:Patient Discharge; D012189:Retrospective Studies; D012307:Risk Factors; D012846:Singapore; D062606:Tertiary Care Centers; D016896:Treatment Outcome
keywords: documentation of reasons; medication discrepancies; physician discharge summaries