gms | German Medical Science

Objective: During a hospital stay, medications are often modified. Some of these modifications reflect intended changes in the treatment regime, others are necessary due to economic or logistic issues, while still others are simply medication errors. While intended changes have to be passed on, the other two should be corrected at discharge. With respect to the ministry of health's current intention to introduce mandatory "discharge prescriptions" for hospitals, we evaluated the quality of medication lists of discharge letters.

Method: We did a retrospective analysis of medication history, treatment plans and discharge letters of patients discharged between March and June 2014 from our hospital. In addition, a pharmacist reviewed the medication lists for possible errors and missing information.

Results: Of 410 patients treated within the desginated period, only 305 complete data sets were available at the time of data analysis. 40 of these patients were excluded because they were admitted on emergency basis and directly transferred to the OR with no formal medication history taken, or because of death in the course of hospitalization.

Of the remaining 265 patients 84% had at least one modification of the medication prior to admission. On the average 4.4 modifications were observed per patient (range 1-16). 76% received at least one additional drug, while in 36% at least one drug was withdrawn. The dosage of one or more drugs was changed in 15% of patients. In 60% the discharge letter omitted crucial information concerning changed medication (mainly the indication for changes). Preoperatively withdrawn drugs were frequently (mistakenly) not re-started at discharge (Metformin in 52%, anticoagulants in 11%.

Only 20% of the letters of patients discharged on antithrombotics and 76% of the letters of patients with ongoing antibiotic treatment contained information on the intended duration for this treatment.

Conclusions: A surprising number of medication errors were identified in discharge letters, and frequently crucial information concerning indications or the duration of ongoing treatments at discharge were missing. Measures to ensure a correct continuation of medication following hospitalization (like the politically intended "discharge prescriptions") have to target medication safety during the entire course of the hospitalization well before discharge.