Background: One of the Joint Commission on Accreditation of Healthcare Organization's National Patient Safety Goals is for hospitals to accurately and completely reconcile patients' medications. Unfortunately, medication histories in charts might bc inaccurate and incomplete. In a thorough medication history, each medication should match a particular reported medical condition. The use of medications without a clear reported indication is of particular concern and has been associated with inappropriate use and polypharmacy.
Objectives: The purposes of this study were to evaluate the occurrence of discrepancies between home medications listed in hospital admission notes and patients' reported medical conditions and to describe the types of medications most often identified as not having a corresponding indication.
Methods: In this retrospective observational study, data were included from adult patients (> or =18 years of age) who were receiving > or =3 home medications on admission to medical wards at a university hospital during a 6-month period. Each home medication listed in the admission note, together with any preadmission paperwork, was matched with an indication listed in the note. Medications were deemed unspecified if an indicated disease state or condition for the medication was not reported.
Results: Data from 121 patients were included. The majority (91.7%) of the patients were admitted to an internal medicine service. Eighty-four patients (69.4%) had > or =1 unspecified medication listed in the admission note. Patients with > or =1 unspecified home medication reported taking a significantly higher number of home medications (10.2 [4.5] vs 7.5 [3.5] in those without unspecified medications; P = 0.007). Thirty-two patients (26.4%) were receiving proton pump inhibitors or histamine type 2 antagonists without a reported indication. Seventeen patients (14.0%) were receiving selective serotonin reuptake inhibitors without a reported indication.
Conclusions: Nearly 70% of patients admitted to a medical ward had > or =1 unspecified medication listed in the admission note. Based on these results, health care professionals must bc careful to obtain and document complete medication histories with matching indications.