An evaluation of the process-related medication risks for elective surgery patients from pre-operative assessment to discharge

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Abstract
Aim To investigate where the process-related medication risks occur in an elective surgery service with a pre-operative assessment clinic (PAC) and make recommendations for how pharmacy services should best be provided. Method The study involved identification of discrepancies in medication history taking, changes that occurred in patients' medication between PAC and admission, and changes that occurred between admission and discharge. Prescribing errors were identified and classified according to whether they occurred on admission, during the inpatient stay or on discharge, and whether they were identified and rectified by the existing pharmacy service. Setting Seventy-six patients recruited from the nurse-led PAC of a 580-bed London teaching hospital between May 2 and June 30, 2000. Key findings The PAC nurse omitted 27 per cent of medications from the medication history; the admitting doctor omitted 37 per cent from the medication history documented in the medical notes and 47 per cent from the inpatient medication chart; the majority of the omissions were complementary and over-the-counter preparations. Twenty-six per cent of patients had changes made to their medication between PAC and admission, and 85 per cent had changes made between admission and discharge. A total of 177 prescribing errors were identified (median of 1 error per patient; interquartile range 0–3), of which 38 per cent occurred on admission, 14 per cent during the inpatient stay and 48 per cent at discharge. Pharmacists made interventions to rectify 59 per cent of the errors. Conclusion Given the large number of changes to patients' medication that occurred between PAC and admission, we would not support the writing of inpatient medication charts or the supply of medication at this stage. For this group of patients in the study hospital, the greatest process-related medication risks occurred on admission and discharge, and pharmacy services should be provided accordingly.