Poor drug history documentation in admission medical notes: Clerking prompts and junior doctor education alone do not significantly reduce errors

Abstract

Introduction: Poor drug history documentation on admission may lead to medication errors; a leading cause of avoidable harm. Aims: 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. Conclusion: The error rate in drug histories is unacceptably high. More research is needed to explore factors involved in such documentation errors.