What is the patient really taking? Discrepancies between surgery and anesthesiology preoperative medication histories

Abstract

Background: Surgical patients may be at risk for medication discrepancies that may lead to medication errors because both the anesthesiologist and the surgeon write separate preoperative medication histories. Methods: A prospective observational study was conducted to examine the extent of medication and allergy discrepancies between surgical and anesthesia preoperative medication histories for patients admitted to two surgical intensive care units in an academic medical center. Results: Of the 79 patient records reviewed, 58 (73%) contained at least one discrepancy, 23% had different allergy information, 56% had different preoperative medications, and 43% had different doses or dosing frequencies listed in the medication histories. Of the 988 allergies, medications, and doses or dosing frequencies documented in the two histories, 456 (46%) contained discrepancies. Of these discrepancies, 20 (5%) were due to different allergies, 293 (64%) to different medications, and 143 (31%) to different doses or dosing frequencies. Conclusions: Discrepancies in preoperative medication histories between surgical and anesthesia records occur in most patients and further work is required to help improve agreement of patient medication histories between services.