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What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories

¹ Department of Pharmacy, Johns Hopkins Medical Institutions, Baltimore, MD, USA
² Department of Surgical Nursing, Johns Hopkins Medical Institutions, Baltimore, MD, USA
³ Departments of Anesthesiology and Critical Care Medicine, Surgery, Health Policy and Management, Nursing; and the Center for Innovations in Quality Patient Care, Johns Hopkins Medical Institutions, Baltimore, MD, USA

Correspondence to:
S A Burda
The Johns Hopkins Hospital, Department of Pharmacy, 600 North Wolfe St, Carnegie 180, Baltimore, MD 21287-6180, USA; sburda1{at}jhmi.edu Background: Surgical patients may be at risk for medication discrepancies that may lead to medication errors because both the anesthesiologist and the surgeon write separate preoperative medication histories.

Methods: A prospective observational study was conducted to examine the extent of medication and allergy discrepancies between surgical and anesthesia preoperative medication histories for patients admitted to two surgical intensive care units in an academic medical center.

Results: Of the 79 patient records reviewed, 58 (73%) contained at least one discrepancy, 23% had different allergy information, 56% had different preoperative medications, and 43% had different doses or dosing frequencies listed in the medication histories. Of the 988 allergies, medications, and doses or dosing frequencies documented in the two histories, 456 (46%) contained discrepancies. Of these discrepancies, 20 (5%) were due to different allergies, 293 (64%) to different medications, and 143 (31%) to different doses or dosing frequencies.

Conclusions: Discrepancies in preoperative medication histories between surgical and anesthesia records occur in most patients and further work is required to help improve agreement of patient medication histories between services.

Keywords: preoperative medication histories; doctor-doctor communication; medication errors; patient safety; allergy

This article has been cited by other articles:

				B. Glintborg, S. E. Andersen, and K. Dalhoff Insufficient communication about medication use at the interface between hospital and primary care Qual. Saf. Health Care, February 1, 2007; 16(1): 34 - 39. [Abstract] [Full Text] [PDF]