Int J Clin Pharm

DOI 10.1007/s11096-017-0519-2

COMMENTARY

‘What is not written does not exist’: the importance of proper

Alfredo Dias de Oliveira-Filho1,2 • Divaldo Pereira de Lyra Jr.1

 Springer International Publishing AG 2017

Abstract Medications are perceived as health risk factors, during transfer is a key step in the procedure; hence, it
because they might cause damage if used improperly. In should be rightly performed. It remains unclear whether
this context, an adequate assessment of medication use interviews, and other investigations about medication use
history should be encouraged, especially in transitions of history have been performed but have not been recorded as
care to avoid unintended medication discrepancies health-care data. Therefore, it is crucial to the improvement
(UMDs). In a case-controlled study, we investigated of medication use safety that documentation of all drug-
potential risk factors for UMDs at hospital admission and related information—even if not directly related to the
found that 150 (42%) of the 358 patients evaluated had one actual event—become routine practice in health-care
or more UMDs. We were surprised to find that there was no organizations, since ‘what is not written does not exist’.
record of a patient and/or relative interview on previous use
of medication in 117 medical charts of adult patients
(44.8%). Similarly, in the medical charts of 52 (53.6%) Keywords Documentation
Medication discrepancies

paediatric patients, there was no record of parents and/or Medication reconciliation
Transitional care
relatives interviews about prior use of medications. One
hundred thirty-seven medical charts of adult patients
(52.4%) and seventy-two medical charts of paediatric Impact on practice
patients (74.2%) had no record about medication allergies
and intolerances. In other words, there was a lack of basic • Documentation of the patient’s medication use history
documentation regarding the patient’s medication use his- at transitions of care should be properly accomplished
tory. As patients move between settings in care, there is in hospital environments.
insufficient tracking of verbal and written information • Efforts to improve written communication of medica-
related to medication changes, which results in a progres- tion information may contribute to enhance implemen-
sive and cumulative loss of information, as evidenced by tation of medication reconciliation processes.
problems associated with clinical transfers and medication Seventeen years ago, the landmark report ‘To Err is
orders. Proper documentation of medication information Human’ was published by the Institute of Medicine, high-
lighting the major need for establishing an international
& Carina Carvalho Silvestre
sense of urgency to reduce patient harm in health care [1].
[Link]@[Link] It is now well known that medications have been observed
as health risk factors because they might cause damage if
1
Laboratory of Teaching and Research in Social Pharmacy used improperly. In this context, adequate assessment of
(LEPFS), Department of Pharmacy, Federal University of
Sergipe, Cidade Universitária ‘‘Prof. José Aloı́sio Campos’’,
medication use history should be encouraged, especially in
Jardim Rosa Elze, São Cristóvão, Sergipe CEP: 49100-000, transitions of care, moments in which patients move from
Brazil one setting of care to another (e.g. hospital admission,
2
School of Nursery and Pharmacy (ESENFAR), Federal discharge and transfer). Medication reconciliation has been
University of Alagoas, Maceió, Alagoas, Brazil the leading strategy—recommended by patient safety

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organizations worldwide—to address medication use his- concluded that medication history errors at hospital
tory, reducing the so-called unintended medication dis- admission are disturbingly common and potentially harm-
crepancies (UMDs), which can be defined as unjustified ful to patients. The review also uncovered important con-
differences between medication used by the patient and the siderations for future studies. First, actual medication
admission medication orders prescribed after hospitaliza- exposure in the hospital is best reflected by admission
tion [2]. medication orders or medication administration records,
A recent meta-analysis concluded that medication and not by physician chart notes. Second, the main com-
reconciliation has been effective in reducing the inci- parator should be a comprehensive medication history that
dence of adverse drug event-related hospital revisits includes an interview, inspection of medication vials or
(67%; risk ratio (RR) 0.33; 95% CI 0.20–0.53), emer- lists, or both, and should involve contacting community
gency department (ED) visits (28%; RR 0.72; 95% CI pharmacies or family physicians.
0.57–0.92) and hospital readmissions (19%; RR 0.81; In a case-control study, we examined potential risk
95% CI 0.70–0.95) compared to usual care groups [3]. factors for UMDs identified at admission among a random
Obtaining the best possible medication history (BPMH) is sample of hospitalized adults and children in a teaching
the first step of the medication reconciliation process. hospital fully integrated into the SUS, at Aracaju, Brazil
More comprehensive than a routine primary medication [8]. Data were obtained by clinical pharmacists through a
history, the BPMH involves two actions: (1) a systematic structured questionnaire from admission medical records,
process to obtain a thorough history of all prescribed and first-day prescriptions, patients’ medical charts, and clini-
non-prescribed medications by using a structured patient cal interview with the patients and/or their carers. Patients
interview; (2) verification of this information with at least admitted in the surgical, medical and paediatric wards that
one other reliable source of information (for example, a remained hospitalized for longer than 24 h were included.
government medication database, medication vials, The case group was composed of patients with at least one
patient medication lists, a community pharmacy, or a UMD identified at admission and the control group was
primary care physician) [4]. composed of patients without UMDs at admission.
This gold standard strategy can be used to obtain an As a result, 150 (42%) of the 358 patients evaluated
accurate medication history at any time of transition of (261 adults and 97 children) had one or more UMDs and
care, for example, admission or discharge. A study by omission was the most common type (85.3%). Surpris-
Monfort et al. [5] found a recurrent failure to transfer ingly, there was no record of a patient and/or relative
needed medication-related information at transitions of interview on previous use of medications in 117 medical
care. The authors concluded that a medication discharge charts of adult patients (44.8%). Similarly, in the medical
list, which they called Best Possible Medication Discharge charts of 52 (53.6%) paediatric patients, there was no
List (BPMDL), is an important tool to summarize medi- record regarding questioning the parents and/or relatives
cation at discharge time as well as medication changes about prior use of medications. Moreover, in 137 medical
previously made during hospitalization, thus avoinding charts of adult patients (52.49%) and 72 medical charts of
unintentional medication discrepancies. paediatric patients (74.22%), there was no record about
Omissions are the most common type of UMDs, and medication allergies and intolerances. In other words, there
may occur when there are no checks on the medication use was a lack of basic documentation regarding the patient’s
history or no record of the data obtained on the use of medication use history. Other studies have addressed this
medications prior to admission. In many countries there are problem, but to our knowledge, ours is the first study to
several sources of medication information, e.g. health-care determine quantitatively this documentation issue [7, 9].
databases; so, when a patient is transferred to the next level After this study was completed, a medication reconciliation
in health care, the current medication overview will be process was implemented in the study setting, and was
available as soon as necessary to the oncoming health staff. performed by pharmacists in order to solve the problems
In Brazil’s Unified Public Health System (SUS) there has highlighted by the investigation, using as a reference the
been considerable progress over the past 20 years, includ- study carried out by Curatolo et al. [10].
ing investments in human resources, science and technol- Barriers to the implementation of BPMH include health-
ogy; however, some challenges persist since there is no care professional disagreement and lack of systematic
integrated information system regarding health care, such approaches to best practices implementation. A study that
as a health system database or integrated data from com- evaluated the perceptions of physicians, nurses and phar-
munity pharmacies [6]. macists about their roles and responsibilities in completing
Tam et al. [7] conducted a systematic review in order to inpatient medication reconciliation revealed poor agree-
describe the frequency, type and clinical importance of ment among clinicians about whose primary role it is to
medication history errors at hospital admission. They obtain and document a medication history [11]. Most

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clinicians believed that maintaining a patient’s list of describe types of medication discrepancies. Using these
medications improves patient care (94–100% agreement). terms is open to interpretation as it is difficult for an
However, when asked whether clinicians other than independent person to determine whether another person’s
themselves should be responsible for an accurate medica- actions were unintentional or not. When the physician
tion list, most nurses (73%) and pharmacists (52%) agreed deliberately changes the therapy based on the clinical sit-
with this statement compared to that reported by residents uation of the patient, the use of such terms seems reason-
(50%) and attending physicians (29%). In addition, no able, although still inconsistent. Thus, proper—systematic,
physicians and only two (6%) nurses and two (9%) phar- continuous, attentive—documentation of medication use
macists believed that acquiring and documenting a history may be an important tool for obtaining BPMH and
patient’s medication history is a multiple responsibility. that, along with a well-designed taxonomy for medication
These findings highlight the need for better clarity of each discrepancies, may decisively improve the medication
role and good communication among team members. As reconciliation process during transitions of care. However,
for the lack of systematic approaches to more accurate this can only be achieved if great efforts are made to
practices, this is characterized by the current non-stan- improve the documentation of medication information and
dardization of medication reconciliation terms [9]. all types of patient evaluations, such as gathering infor-
Almanasreh et al. [12] stated that the inconsistency mation about the reasons for medication changes during
between prestigious international organizations has con- transitions of care. Furthermore, proper documentation of
tributed to heterogeneity between medication reconcilia- medication information during transfer is a key step after
tion interventions and how they are evaluated. As a procedure; hence, it should be rightly performed. It remains
consequence, published studies on medication reconcilia- unclear whether interviews, questionings, and other
tion did not utilize a gold standard medication list or a investigations about medication use history are performed
BPMH [13]. accomplished but have not been recorded as health-care
As patients move between environments in care, there is data.
insufficient tracking of verbal and written information If a crucial step for patient evaluation was performed
related to medication changes, which leads to the propa- and not properly documented, how can the health-care
gation of deficits of such changes, as evidenced by prob- team know of its existence and rely on it for medication
lems associated with clinical handovers and medication reconciliation and other procedures in order to enhance
orders [14]. Better communication about medications patient safety? Therefore, it is crucial to the improvement
across the continuum of care may reduce medication-re- of medication use safety that documentation of all drug-
lated adverse events and improve patient adherence to related health practices—even if not directly related—be-
therapy. Improved communication about medications on come a routine practice in health-care organizations, since
transfer and at discharge may also decrease return visits to ‘what is not written does not exist’.
the emergency department and unplanned hospital read-
missions, which together can significantly reduce the Funding This study was funded by the Coordination for the
Improvement of Higher Education Personnel (CAPES), Northern
consumption of health-care resources [4, 15–17]. Banking Sector, Block 2, L, Lot 06, CAPES Building. Zip Code
We believe that a lack of documentation and possible 70.040-031 – Brası́lia, DF - Brazil.
absence of investigation into the patient’s medication use
history at hospital admission may be related to a deficiency Conflicts of interest All authors declare that they have no conflict of
interest.
in the training of health professionals. They should be
aware of the importance of measuring and recording the
medication use history, and the lack of integration of the
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