June 5, 2019
An examination of the EHRs of a cohort of ophthalmology patients revealed that one-third had at least one discrepancy between the medications discussed in the clinician’s notes and those on the medication list, according to reporting by Shelley Zalewski on the Michigan Health Lab blog, a publication of the University of Michigan Medical School.
The study, published in JAMA Ophthalmology, was conducted by investigators at the University of Michigan Kellogg Eye Center. The team examined medication-related information contained in the EHRs of patients treated for microbial keratitis between July 2015 and August.
In a typical appointment, a provider verbally communicates medication instructions to the patient. At the same time, notes from that discussion are typed into an unstructured or “free text” section of the patient’s EHR by either the doctor, a technician or a medical scribe.
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The patient then receives a medication list generated from the EHR as part of a printed after-visit summary.
“That summary should confirm how the provider intends medications to be used,” says Maria Woodward, MS, MD, assistant professor of ophthalmology and the study’s lead author and a health services researcher at the U-M Institute for Healthcare Policy and Innovation.
The team found that one-third of patients had at least one medication mismatch in their records.
While this is the first study focused on ophthalmic medications, the results are consistent with studies of medications used in other medical specialties. “This level of inconsistency is a red flag,” Woodward says. “Patients who rely on the after-visit summary may be at risk for avoidable medication errors that may affect their healing, or experience medication toxicity.”
Potentials shortcomings in patient care arise when data about medications, and other information, are captured in multiple formats in multiple locations. “The only way to ensure that the medication list is completely accurate is to double-document. The same information must be entered into the clinician’s notes and the formal medication list — two separate places,” Woodward says.