Introduction

Transition of care, including hospital admission, transfer between wards, and hospital discharge,1 increases the possibility of communication failures between healthcare professionals,2 which can lead to medication errors.3 This is attributable to inaccurate or insufficient sharing of information, especially medication history, resulting in discontinuity of care4 and increased morbidity.5

Inevitably, medication changes occur in the acute medical phase of hospitalization (e.g., addition, discontinuation, and change in dosage or frequency of medications).6 Maintaining appropriate medications throughout the in-hospital transition and after discharge is important, and improper resumption of preadmission medication must be avoided.7 The sharing of information among healthcare professionals is of vital importance, especially when changes in prescription orders are made intentionally.8–10 When the physician writes a daily order via the electronic health record (EHR), documenting the intent for medication changes enhances communication among hospital staff working across different shifts and locations. This documentation facilitates patient-centered, real-time communication without requiring extensive review of medical records by various healthcare professionals.11 Moreover, such documentation aids in medication reconciliation (MR), to identify discrepancies and ensure accurate and complete information transfer during the transition of care.3 Sharing up-to-date medication information promotes safe care and reduces erroneous medication discrepancies and communication gaps.12–14

However, despite its critical importance, effective communication through documentation of medication information remains a challenge in real-world clinical practice, with significant gaps in documentation identified in several studies. For instance, a case-controlled study reported that previous medication history was not properly documented at admission in 44.8% of patients.15 An observational study reported that 63% of discharge letters had complete medication-related information.4 Another study reported that 27% of medications withdrawn during hospitalization because of adverse events were re-prescribed after discharge, indicating poor transfer of information.16 Yet, little is known about the factors influencing documentation practices in hospitals. However, recent research suggests that physicians who receive training for documentation are more likely to provide appropriate documentation, indicating the potential benefits of training in enhancing knowledge and familiarity with documentation guidelines.17 Nonetheless, further investigation is required to elucidate the underlying reasons for under-documentation.

It is important to note that a discharge summary can effectively communicate the in-hospital medication changes of a patient upon discharge, although the quality of the content is often insufficient.18,19 Scattered patient information across various parts of the EHRs and the vast amount of cumulative daily progressive notes make it difficult to write a high-quality discharge summary in a limited time of discharge process. Therefore, it is crucial to provide an accurate summary of medication changes, rather than solely focusing on the discharge medications list.20,21 However, current EHRs separate the medical recording and prescription work, which often hinders physicians from integrating updated medication changes into discharge summary.

In light of these challenges, we hypothesized that real-time documentation of intent of physicians’ on in-hospital medication changes may facilitate health professionals engaged in patient care, thus ultimately enhancing patient safety by reducing documentation errors at discharge. Therefore, we aimed to investigate the impact of documenting in-hospital medication changes on documentation errors at discharge and identify the factors associated with such errors. Additionally, we aimed to explore how such physicians’ documentation improves communication between pharmacists and physicians from the pharmacist’s perspective.

Methods Study Design and Patient Selection

This was a retrospective cohort study conducted at acute medical unit (AMU) of the Hospital Medicine Centre of Seoul National University Bundang Hospital, a tertiary academic hospital in South Korea. Data were retrieved from the EHR. The collected data included demographics, medication lists (preadmission, in-hospital, discharge), progress notes, discharge summaries, diagnoses, comorbidities, laboratory data, and length of stay.

All patients admitted to the AMU of the Hospital Medicine Centre between April–June 2020 were included. The exclusion criteria were patients who were admitted for tests or surgeries, patients with no medication changes, patients who died or were readmitted during the study period, patients without preadmission medications, and patients who were transferred to the rehabilitation or surgical wards. The diagnoses at admission were classified using the International Classification of Diseases (ICD)-11 codes.

The AMU is a hospitalist-managed medical unit where approximately 200 internal medicine patients with acute illness are admitted through the emergency department (ED) or outpatient clinics every month. When admitted to the AMU, patients receive a rapid assessment, hospitalist management, and, if necessary, a specialist consultation. They are either discharged from the hospitalist-managed ward or transferred to a non-hospitalist-managed ward for further care.22

In the AMU, there are 9 hospitalists with clinical experience ranging from 7 to 19 years. They specialize in various fields such as gastroenterology, nephrology, rheumatology, endocrinology, geriatrics, infectious diseases, and others. Two designated pharmacists participate as team members in the AMU: a senior pharmacist with 9 years of clinical practice experience in hospital and a resident pharmacist who is trained by the senior pharmacist. Once created, medication lists with free-text documentation were validated daily during admission by corresponding physician. The designated pharmacists conducted a daily review of medication lists. Upon identifying undocumented medication discrepancies, they promptly contacted the corresponding physician to clarify whether the change was intentional or erroneous. Subsequently, pharmacists documented their findings in the MR tab within 24 hours of the patient’s admission. The MR tab is a specialized section within our EHR system, as described by Park et al, which serves as a dedicated interface for communication between physicians and pharmacists regarding medication management.23

Appropriate Documentation of Medication Change

To identify any medication discrepancies during hospitalization, two designated pharmacists compared the preadmission and prescribed medication lists. Only scheduled medications were included, and pro re nata medications, over-the-counter medications, and medications for external use were excluded. Identified medication discrepancies were classified into “unintentional”, “documented intentional”, and “undocumented intentional”. A discrepancy was classified as “documented intentional” if the medication change was documented in the patient’s medical record (in the medication section and progress note) and clarified by free-text documentation in the electronic order entry system.

Further, we classified each discrepancy into “addition of new medication”, “discontinuation of preadmission medication”, “change of dose”, “change of frequency”, and “change of formulation”. Only the first change of each medication per patient was included, even if they were changed multiple times compared with the preadmission medication list. The documentation rate of changed medication per patient was defined as follows:

Patients were classified as “fully documented” (FD) if the documentation rate of changed medication was complete and otherwise as “partially documented” (PD).

Documentation Error at Discharge

We identified whether the information about in-hospital medication changes was documented in the discharge summary or discharge medication list. Any undocumented medication change between preadmission and discharge was considered a “documentation error at discharge” and was further classified based on the drug classes.

Pharmacists’ Survey

To identify the impact of appropriate documentation on the pharmacists, we conducted an online survey with 13 clinical pharmacists who work as designated pharmacists. The survey had three themes, which were as follows: 1) improvement in understanding, 2) improvement in communication, and 3) improvement in time saving. For each theme, there was a 5-point Likert scale question measuring improvement, along with an open-ended question to express personal opinions and to allow the pharmacists to share their own experiences. All surveyed pharmacists provided informed consent.

Statistical Analysis

Descriptive statistics were used to express mean ± standard deviation for continuous variables and number and percentage for categorical variables. Univariate and multivariate logistic regression analyses were conducted to determine possible independent variables associated with documentation errors at discharge. The variables analyzed included age, Charlson comorbidity index (CCI), the total length of hospital stay, day of discharge, discharged ward, residence after discharge, the number of physicians attending the patient during hospitalization, the number of preadmission medications, and the appropriateness of documentation. The variables that were statistically significant in univariate logistic regression were included in the multivariate model. The results of the regression analyses were presented as odds ratios (ORs) and 95% confidence intervals (CIs), and statistical significance was set at p < 0.05. Data management and statistical analyses were performed using SAS version 9.4 (SAS Institute, Inc., Cary, NC, USA).

Results Baseline Characteristics of the Study Population

Between April 2020 and June 2020, 731 patients were admitted to the AMU. Exclusions included patients admitted for tests or surgeries (n = 136), those without medication discrepancies (n = 39), readmissions during the study period (n = 23), deaths during the study period (n = 35), those without preadmission medication (n = 70), and those transferred to rehabilitation or surgical wards (n = 28). After these exclusions, 400 patients were enrolled in this study (Figure 1).

Figure 1 Flow chart of the study population and study design.

The mean age of total patients was 69.0 years (67.5 in FD and 71.5 in PD, p < 0.01) and 51.0% were female. The average number of preadmission medications was 7.6 (6.8 in FD and 8.8 in PD, p < 0.01). Of the total patients, 68.5% of the patients were discharged from hospitalist-managed ward. Characteristics of the study population are presented in Table 1.

Table 1 Baseline Characteristics of Study Population

Medication Discrepancies and Appropriateness of Documentation

In total, 1092 episodes of intentional medication discrepancies and 109 episodes of unintentional medication discrepancies were identified in 400 patients during hospitalization (Figure 1). About 25.7% of intentional medication discrepancies were undocumented.

On average, patients had at least 1.9 and 2.7 episodes of unintentional and intentional discrepancies during admission, respectively. The average rate of documenting in-hospital medication changes was 79.7% per patient. The addition of new medications was adequately documented in 89.9% of episodes, whereas the discontinuation of preadmission medications was documented only in 56.7% of cases (see Supplementary Figure 1). The classification of changed medications during hospitalization is presented in Supplementary Table 1.

Characteristics of FD and PD

After classifying patients according to the documentation rate of changed medications, the FD group accounted for 61.3% (n = 245) of the total population, and 38.8% (n = 155) belonged to the PD group (Figure 1). The mean age was significantly higher in the PD group than in the FD group (67.5 vs 71.5, p < 0.01). The average number of preadmission medications was also significantly higher in the PD group than in the FD group (6.8 vs 8.8, p < 0.01). There was no significant difference in the total length of hospital stay and length of AMU stay (Table 1).

Documentation Errors at Discharge

Documentation errors at discharge occurred in 46.3% (n = 185) of total patients. In the FD group, 33.9% (83 of 245) had documentation errors at discharge, while 65.8% (102 of 155) in the PD group had documentation errors at discharge (p < 0.001) (Figure 2). We identified 602 episodes of documentation errors at discharge. Four major drug classes with documentation errors at discharge were identified: anti-infectives (150 episodes, 24.9%), anti-hypertensives (113 episodes, 18.8%), anti-diabetics (86 episodes, 14.3%), and nervous system drugs (85 episodes, 14.1%) (Figure 3).

Figure 2 The difference in documentation errors at discharge between FD and PD.

Figure 3 Number and percentages of documentation errors at discharge according to drug classes. *Gastrointestinal drugs, anti-hemorrhagics, urologicals, pituitary and hypothalamic hormones, thyroid drugs, anti-neoplastics, muscle relaxants, anti-gout drugs, and drugs for treating obstructive airway disease.

Factors Associated with Documentation Errors at Discharge

The univariate logistic regression analysis revealed that having more than three intentional medication discrepancies (OR, 3.82; 95% CI, 2.33–6.28), belonging to the PD group (OR, 3.76; 95% CI, 2.46–5.74), being discharged from a non-hospitalist-managed ward (OR, 2.66; 95% CI, 1.72–4.12), staying at the hospital for more than 11 days (OR, 2.62; 95% CI, 1.52–4.50), being discharged to a nursing or hospice hospital (OR, 2.44; 95% CI, 1.30–4.55), and being 80 years or older in age (OR, 1.71; 95% CI, 1.00–2.94) were the factors associated with documentation errors at discharge.

The multivariate logistic regression analysis revealed that three factors were significantly associated with documentation errors at discharge: belonging to the PD group (adjusted OR [aOR], 2.84; 95% CI, 1.75–4.62), being discharged from a non-hospitalist-managed ward (aOR, 1.96; 95% CI, 1.16–3.31), and having more than three intentional medication discrepancies compared with having one (aOR, 1.92; 95% CI, 1.08–3.42) (Table 2).

Table 2 Factors Associated with Documentation Errors at Discharge

Impact of Documenting Medication Changes on Pharmacists’ Workload

Ten out of 13 pharmacists (77%) chose “strongly agree” in both of improvement in understanding and communication. They said it was possible to understand the physician’s intention of the changes in pre-admission medications and clearly identify medication changes according to the changes in lab data. For the communication improvement, they said they could define either the medication change was intended or an error, therefore they could avoid unnecessary confirmation procedures and instead, spend more effort to other more important communication. For the time efficiencies, 46% chose “strongly agree” and another 46% chose “agree”. They were able to catch the medication changes right away, so it saved their time to additionally check other records. Furthermore, the average 9.3 minutes were saved due to the documentation (see Supplementary Figure 2 and Supplementary Table 2).

Discussion

In this study, we showed that appropriate documentation of medication changes during hospitalization was associated with a decreased rate of documentation errors at discharge. It is facilitated by timely free-text communication on electronic order entry system allowing up-to-date medication lists. This study underscores the value of real-time documentation in fostering effective interprofessional collaboration, improving communication efficiency, and streamlining medication management processes. By expediting the recognition and comprehension of medication changes, pharmacists can dedicate more time and resources to patient-centered care, ultimately leading to enhanced healthcare outcomes.

Ensuring continuous availability of relevant medication information is important for safe medication use, as incomplete or incorrect documentation of medication changes may contribute to improper clinical decision-making.11,15 In our study, it was observed that patients in the PD group were older and had a higher medication count compared to those in the FD group. This can be explained by the fact that, as individuals age, they frequently require multiple medications to manage chronic conditions, which increases the medication burden. This heightened complexity may contribute to a higher likelihood of undocumented medications.24 Our study found that patients in the FD group had fewer documentation errors at discharge compared to the PD group (33.9% vs 65.8%). This finding suggests that documentation and sharing of in-hospital medication changes will increase the likelihood of documenting medication changes at discharge, thus reducing medication errors.

The reduced rate of documentation errors at discharge in patients with appropriate documentation of medication change is possibly attributable to several factors. First, the treatment of a patient during transition, especially in acute medical care, may involve many healthcare professionals and frequent changes in medication regimens.25 Therefore, timely documentation of medication changes can help ensure the continuity of patient care by multidisciplinary team members and reduce errors. Moreover, during hand-offs, this documentation will aid the corresponding healthcare professionals in completing the discharge summary, and, specifically, the discharge prescription list.25,26 Second, if physicians promptly document in-hospital medication changes using free-text function of electronic order entry system, writing discharge summaries will be easier and time-saving without needing to track the previous medical records. A study by Cornu et al showed that 47.6% of patients had inaccurate medication history in the discharge summary.27 Discontinuity of medication information is a major contributing factor to discontinuity of care. The health and social care regulatory body of the United Kingdom has issued recommendations regarding the information provided on medication changes at discharge.28 Indeed, patients were less likely to be readmitted when physicians had their prior discharge summaries, indicating that medication information and clinical outcomes are relevant especially after discharge.29,30

In the risk factor analysis, we found that patients who had three or more intentional medication discrepancies were more likely to experience documentation errors at discharge. This finding is consistent with a previous study, which reported that the increasing number of medications was associated with writing errors in discharge summaries.24 Another study suggested a positive relationship between the number of changed medications and documentation errors at discharge.31 In light of improving organizational and professional culture, these results suggest that prompt documentation of in-hospital medication changes by prescribers can enhance medication safety.32

Moreover, patients discharged from hospitalist-managed AMUs were less likely to have documentation errors at discharge compared to those discharged from non-hospitalist-managed wards. This might be partly explained by differences in ward characteristics. Currently, in our institution, hospitalists are the attending physicians as well as the primary care providers at AMUs, whereas resident doctors, still in training, are the primary care providers in non-hospitalist-managed wards. Previous studies have found that medication errors at discharge are more common with prescriptions by junior doctors with less than 3 years of experience,33 who often omit medication details, especially medication changes, in discharge summaries.34 In addition to time constraints owing to the workload and lack of knowledge, factors contributing to prescribing errors by junior doctors include inadequate training, low perceived importance of prescribing, lack of self-awareness of errors, and lack of communication.35–37 Therefore, to engage physicians in thorough documentation and enhance patient safety, hospitals should provide education, streamline the documentation workflows, and emphasize the benefits of comprehensive documentation. Additionally, fostering a culture of accountability and providing incentives for documentation are crucial for encouraging physicians to maintain high standards in documentation practices. Implementing automated documentation system in the EHR, as suggested by Poldervaart et al,38 could further improve medication change documentation, but optimizing the system to accurately reflect physician’s intent is necessary.

Notably, the most frequently identified undocumented discrepancy was the discontinuation of medications. When the intended discontinuation is not documented, the discontinued medication can accidentally be restarted during the physician hand-off process,39 which may result in adverse effects.40 Previously, no studies have analyzed the various types of undocumented discrepancies; therefore, we could not compare this finding with others. However, we highlight the importance of proper documentation when discontinuing medications.

The major drug classes associated with documentation errors at discharge were similar to those reported in a previous study (ie, drugs for the cardiovascular system, central nervous system, and endocrine system).37 However, in the present study, anti-infectives were associated with increased documentation errors at discharge. Since 68.3% of patients in AMU received anti-infectives, documentation errors were frequent in that drug class. Documenting clinical indications and duration of anti-infectives in EHR is recognized as a standard of good practice, preventing unnecessary and inappropriate use of anti-infectives.41 By properly documenting the history and indications of the use of anti-infectives, physicians can evaluate the appropriateness of the treatment and identify resistance patterns, making it easier to decide whether to stop or change the treatment.42

The online survey revealed that the majority of pharmacists expressed favorable attitudes toward physicians’ real-time documentation of medication changes. This documentation provided valuable insights into the physicians’ intentions and improved communication, ultimately saving time for pharmacists. While the roles of pharmacists may vary between hospitals, those in this hospital are responsible for both dispensing medications and clinical duties, leaving insufficient time for patient reviews. Survey responses from pharmacists indicated that appropriate documentation significantly reduces the time spent on patient reviews, thereby substantially alleviating their workload.

The present study has several limitations to be considered when interpreting its results. First, it was a retrospective study conducted at a single tertiary hospital, limiting generalizability of the findings. However, its retrospective nature ensured that physicians were unaware of this study when documenting, indicating no bias to the documentation activity. Second, we only analyzed patients who were admitted to the AMU via the emergency department or outpatient clinics. Therefore, our findings may not be comparable with the documentation practice in patients admitted directly to other wards. Third, FD and PD were arbitrarily defined to balance the number of patients in each group. As the documentation rate of more than half of the population was 100%, we set the cut-off rate at 100%. Fourth, we could not ascertain the specific reason for medication changes, as most documentations lacked this information. Documenting the reason for medication changes in medical records can facilitate decision-making for every patient, considerably saving time and enabling the physicians to attend to other patients in need.25 Therefore, future studies should evaluate the impact of documenting reasons for medication changes. Finally, we could not investigate the impact of documentation errors at discharge on clinical outcomes. It is known that improved communication regarding medication changes across the continuum of care may reduce adverse effects15 and may further decrease emergency department visits and unplanned hospital readmissions.20 Therefore, further studies are needed to investigate the effect of documentation errors on clinical outcomes.

Our study possesses several strengths. First, to our knowledge, this is the first study conducted in Korea to analyze the impact of in-hospital documentation on medication safety at discharge. Second, we included consecutive hospitalized patients in the AMU over a specific period, effectively minimizing selection bias, increasing the validity of our findings. Additionally, the substantial sample size of 400 medication records enhances the generalizability of our findings. Third, we conducted a thorough review of patient’s medical records, including progression notes, and MR tab to accurately identify medication discrepancies. This comprehensive approach allowed us to detect medication discrepancies with greater precision. Fourth, we demonstrated the effectiveness of communication via documentation on EHR between designated pharmacists and physicians. Such behavioral intervention, which incurs no cost and requires low technology, has culturally beneficial impacts on interprofessional communications, further promoting patient safety.

Conclusions

In conclusion, our study underscores the critical role of real-time documentation of in-hospital medication changes in enhancing patient safety during transitions of care. Through our retrospective cohort study, we observed a significant decrease in documentation errors at discharge among patients with fully documented medication changes, highlighting the importance of timely and accurate documentation. Pharmacists’ favorable attitudes toward physicians’ real-time documentation further emphasize the value of effective communication between pharmacists and physicians and information sharing in medication management. The findings of this study might help healthcare institutions develop strategies to improve documentation practices and enhance patient safety during hospitalization and discharge. Overall, our findings suggest that proper documentation of medication changes can lead to improved medication reconciliation, reduced discrepancies at discharge, and ultimately, enhanced communication between healthcare professionals during care transitions.

Abbreviations

EHR, electronic health record; MR, medication reconciliation; AMU, acute medical unit; ED, emergency department; ICD, International Classification of Diseases; FD, fully documented; PD, partially documented; CCI, Charlson comorbidity index; OR, odds ratio; CI, confidence interval; aOR, adjusted OR.

Ethics Approval

The Institutional Review Board of Seoul National University Bundang Hospital (IRB: B-2008-633-103, approval date August 06, 2020) approved this study.

Acknowledgments

We would like to thank Editage for English language editing. The abstract of this paper was presented at the 81st International Pharmaceutical Federation (FIP) World Congress of Pharmacy and Pharmaceutical Sciences as an oral presentation: https://pharmacyeducation.fip.org/pharmacyeducation/article/download/2480/1631/14583.

Funding

The authors have not received any specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

Disclosure

The authors report no conflicts of interest in this work.

References

1. Bishop MA, Cohen BA, Billings LK, Thomas EV. Reducing errors through discharge medication reconciliation by pharmacy services. Am J Health Syst Pharm. 2015;72(17 Suppl 2):S120–6.

2. World Health Organization. Medication without harm; 2017. Available from: https://www.who.int/initiatives/medication-without-harm. Accessed January20, 2024.

3. World Health Organization [homepage on the Internet]. Medication Reconciliation Implementation Guide; 2014. Available from: https://www.who.int/publications/m/item/high5s-implementation-guide-medication-reconciliation. Accessed January20, 2024.

4. Uitvlugt EB, Siegert CE, Janssen MJ, Nijpels G, Karapinar-çarkit F. Completeness of medication-related information in discharge letters and post-discharge general practitioner overviews. Int J Clin Pharm. 2015;37(6):1206–1212.

5. Bergkvist A, Midlöv P, Höglund P, Larsson L, Bondesson A, Eriksson T. Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol. 2009;65(10):1037–1046.

6. Nickerson A, MacKinnon NJ, Roberts N, Saulnier L. Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q. 2005;8:65–72.

7. Grischott T, Zechmann S, Rachamin Y, et al. Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT. Implement Sci. 2018;13(1):155.

8. Institute for Healthcare Improvement, Cambridge. How-to Guide: prevent adverse drug events by implementing medication reconciliation; 2011. Available from: www.ihi.org. Accessed January20, 2024.

9. Australian Pharmaceutical Advisory Council. Guiding principles to achieve continuity in medication management; 2022. Available from: https://www.health.gov.au/resources/publications/guiding-principles-to-achieve-continuity-in-medication-management. Accessed January20, 2024.

10. Pharmaceutical Services Negotiating Committee. Moving patients, moving medicines, moving safely; 2005; Available from: https://cpe.org.uk/wp-content/uploads/2013/07/Moving20Medicines20new1.pdf. Accessed January20, 2024.

11. Hammer A, Wagner A, Rieger MA, Manser T. Assessing the quality of medication documentation: development and feasibility of the MediDocQ instrument for retrospective chart review in the hospital setting. BMJ Open. 2019;9(11):e034609.

12. Fernandes BD, Almeida P, Foppa AA, Sousa CT, Ayres LR, Chemello C. Pharmacist-led medication reconciliation at patient discharge: a scoping review. Res Social Adm Pharm. 2020;16(5):605–613.

13. Rose AJ, Fischer SH, Paasche-Orlow MK. Beyond Medication Reconciliation: the Correct Medication List. JAMA. 2017;317(20):2057–2058.

14. Sardaneh AA, Burke R, Ritchie A, McLachlan AJ, Lehnbom EC. Pharmacist-led admission medication reconciliation before and after the implementation of an electronic medication management system. Int J Med Inform. 2017;101:41–49.

15. Silvestre CC, Santos LMC, de Oliveira-Filho AD, de Lyra DP. ‘What is not written does not exist’: the importance of proper documentation of medication use history. Int J Clin Pharm. 2017;39(5):985–988.

16. van der Linden CM, Kerskes MC, Bijl AM, Maas HA, Egberts AC, Jansen PA. Represcription after adverse drug reaction in the elderly: a descriptive study. Arch Intern Med. 2006;166(15):1666–1667.

17. Kasaye MD, Beshir MA, Endehabtu BF, et al. Medical documentation practice and associated factors among health workers at private hospitals in the Amhara region, Ethiopia 2021. BMC Health Serv Res. 2022;22(1):465.

18. Weetman K, Spencer R, Dale J, Scott E, Schnurr S. What makes a “successful” or “unsuccessful” discharge letter? Hospital clinician and General Practitioner assessments of the quality of discharge letters. BMC Health Serv Res. 2021;21(1):349.

19. Callen J, McIntosh J, Li J. Accuracy of medication documentation in hospital discharge summaries: a retrospective analysis of medication transcription errors in manual and electronic discharge summaries. Int J Med Inform. 2010;79(1):58–64.

20. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):397–403.

21. Ooi CE, Rofe O, Vienet M, Elliott RA. Improving communication of medication changes using a pharmacist-prepared discharge medication management summary. Int J Clin Pharm. 2017;39(2):394–402.

22. Ohn JH, Kim NH, Kim ES, et al. An Acute Medical Unit in a Korean Tertiary Care Hospital Reduces the Length of Stay and Waiting Time in the Emergency Department. J Korean Med Sci. 2017;32(12):1917–1920.

23. Park B, Baek A, Kim Y, et al. Clinical and economic impact of medication reconciliation by designated ward pharmacists in a hospitalist-managed acute medical unit. Res Social Adm Pharm. 2021.

24. Grimes TC, Duggan CA, Delaney TP, et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011;71(3):449–457.

25. Mathioudakis A, Rousalova I, Gagnat AA, Saad N, Hardavella G. How to keep good clinical records. Breathe. 2016;12(4):369–373.

26. Elliott RA, Tran T, Taylor SE, et al. Gaps in continuity of medication management during the transition from hospital to residential care: an observational study (MedGap Study). Australas J Ageing. 2012;31(4):247–254.

27. Cornu P, Steurbaut S, Leysen T, et al. Discrepancies in medication information for the primary care physician and the geriatric patient at discharge. Ann Pharmacother. 2012;46(7–8):983–990.

28. Care Quality Commission. Managing patients’ medicines after discharge from hospital; 2009. Available from: https://www.centreformedicinesoptimisation.co.uk/managing-patients-medicines-after-discharge-from-hospital-a-national-study-from-The-care-quality-commission/. Accessed January20, 2024.

29. van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med. 2002;17(3):186–192.

30. Bell CM, Schnipper JL, Auerbach AD, et al. Association of communication between hospital-based physicians and primary care providers with patient outcomes. J Gen Intern Med. 2009;24(3):381–386.

31. McMillan TE, Allan W, Black PN. Accuracy of information on medicines in hospital discharge summaries. Intern Med J. 2006;36(4):221–225.

32. Machen S, Jani Y, Turner S, Marshall M, Fulop NJ. The role of organizational and professional cultures in medication safety: a scoping review of the literature. Int J Qual Health Care. 2019;31(10):G146–g157.

33. Abdel-Qader DH, Harper L, Cantrill JA, Tully MP. Pharmacists’ interventions in prescribing errors at hospital discharge: an observational study in the context of an electronic prescribing system in a UK teaching hospital. Drug Saf. 2010;33(11):1027–1044.

34. Legault K, Ostro J, Khalid Z, Wasi P, You JJ. Quality of discharge summaries prepared by first year internal medicine residents. BMC Med Educ. 2012;12:77.

35. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002;359(9315):1373–1378.

36. Bannan DF, Aseeri MA, AlAzmi A, Tully MP. Understanding the causes of prescribing errors from a behavioural perspective. Res Social Adm Pharm. 2019;15(5):546–557.

37. Tan B, Mulo B, Skinner M. Transition from hospital to primary care: an audit of discharge summary - medication changes and follow-up expectations. Intern Med J. 2014;44(11):1124–1127.

38. Poldervaart JM, van Melle MA, Willemse S, de Wit NJ, Zwart DLM. In-hospital prescription changes and documentation in the medical records of the primary care provider: results from a medical record review study. BMC Health Serv Res. 2017;17(1):792.

39. Cornu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Ann Pharmacother. 2012;46(4):484–494.

40. Caleres G, Modig S, Midlov P, Chalmers J, Bondesson A. Medication Discrepancies in Discharge Summaries and Associated Risk Factors for Elderly Patients with Many Drugs. Drugs Real World Outcomes. 2020;7(1):53–62.

41. Solomon SL, Oliver KB. Antibiotic resistance threats in the United States: stepping back from the brink. Am Fam Physician. 2014;89(12):938–941.

42. Cooke FJ, Holmes AH. The missing care bundle: antibiotic prescribing in hospitals. Int J Antimicrob Agents. 2007;30(1):25–29.