title: Poor drug history documentation in admission medical notes: clerking prompts and junior doctor education alone do not significantly reduce errors.
abstract: BACKGROUND
  Poor drug history documentation on admission may lead to medication errors; a leading cause of avoidable harm.
  
  
  OBJECTIVE
  To assess the quality of drug histories in the notes of patients admitted to an emergency assessment unit and impact of interventions to improve documentation.
  
  
  METHODS
  Data were collected on the accuracy of documentation in 281 drug histories including errors of omission, frequency and dose.
  
  
  RESULTS
  The mean error rate was high at more than five per drug history. Omitted drugs included warfarin and long-term steroids, the consequences of which were potentially serious. Clerking prompts and education alone did not improve errors significantly.
  
  
  CONCLUSIONS
  The error rate in drug histories is unacceptably high. More research is needed to explore factors involved in such documentation errors.
authors.affiliation: Principal Clinical Pharmacist, Mid Essex Hospitals NHS Trust, Broomfield, Essex CM1 7ET.
authors.forename: Maria
authors.initials: M
authors.lastname: Richards
authors.affiliation: Junior Doctor, Mid Essex Hospitals NHS Trust, Broomfield, Essex.
authors.forename: Dominic
authors.initials: D
authors.lastname: Espitalier-Noel
authors.affiliation: Junior Doctor, Mid Essex Hospitals NHS Trust, Broomfield, Essex.
authors.forename: Hannah
authors.initials: H
authors.lastname: Stacey
authors.affiliation: Junior Doctor, Mid Essex Hospitals NHS Trust, Broomfield, Essex.
authors.forename: Jessica
authors.initials: J
authors.lastname: Thomerson
authors.affiliation: Consultant in Acute Medicine and Clinical Pharmacology, Mid Essex Hospitals NHS Trust, Broomfield, Essex.
authors.forename: Tehreem
authors.initials: T
authors.lastname: Butt