An audit of medicines information quality in electronically generated discharge summaries: evidence to meet the Australian national safety and quality health service standards

Background: Problems with achieving the continuum of medicines management are long-standing. Audits are valuable in improving medication management and the quality and safety of healthcare systems. Aim: To evaluate the accuracy and timeliness of electronic discharge summaries (EDS) provided to patients and their primary care providers at discharge. This was a forerunner to the study hospital’s National Accreditation Examination and for routine safety and quality evaluation. Methods: This study was a retrospective audit using an adaptation of the NSW indicator 5.3, ‘Percentage of discharge summaries that include medication therapy changes and explanations for changes’ (National quality use of medicines indicators for Australian Hospitals. ACSQHC, Sydney, NSW, 2014). The additions to the NSW tool included: assessing the completion and timeliness of delivery to primary health care providers, and the accuracy of the information. Results: In patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post-discharge was also assessed. It indicated 46% accuracy, with the majority of erro rs being omissions of required medicines. None of the EDSs included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short-term therapy, such as antibiotics, 71% of EDSs had documented a plan for short-term therapies to be completed in the community. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Results: In patients leaving hospital, 75% had a hospital EDS completed, with 46% completed within the recommended 48 h from discharge. For an EDS to be delivered, a primary healthcare provider must be nominated by the patient. This occurred in 53% of our sample. Accuracy of information on what medicines patients should use post-discharge was also assessed. It indicated 46% accuracy, with the majority of erro rs being omissions of required medicines. None of the EDSs included documented reasons for changes to medicines, in the provided table, to the primary healthcare provider. In patients on a short-term therapy, such as antibiotics, 71% of EDSs had documented a plan for short-term therapies to be completed in the community. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Conclusion: The lack of information on the primary care provider recorded in the patient’s clinical system and discharge summaries, limited the timely transfer of essential information on post-discharge medicine management to the patient’s primary care provider. Work has commenced on an educational program to improve data entry of the patient’s primary care provider when they are admitted, and plans to improve compliance with the EDS policy. Refereed/Peer-reviewed