Accuracy of information on medication use and adverse drug reactions recorded in pregnancy hand-held records

Abstract

Background: Pregnancy hand-held records (PHR) are a personally controlled health record utilised in the promotion of continuity of care across pregnancy by providing a single resource for the recording of pregnancy-related health information. Aims: To determine the accuracy of the PHR in relation to information on medications and adverse drug reactions (ADRs) and to examine the frequency and nature of any identified discrepancies. Materials and Methods: A 12-week prospective clinical audit of 300 women admitted to either the antenatal or postnatal ward at a tertiary-level maternity hospital. A detailed medication history was completed for each woman by a pharmacist, with women interviewed about medication use prior to and during their pregnancy as well as any ADRs. The medication history and PHR were compared to identify discrepancies. Results: Medication discrepancies were extremely common, with 254 (84.7%; 95% CI 80.6–88.8%) women having at least one or more medication-related discrepancy involving 686 (55%; 95% CI 52.2–57.8%) prescription and nonprescription medications. Most common reasons for prescription medication discrepancies included the medication details being incomplete (44%), missing (29%) or incorrect (17%). ADRs and allergy discrepancies were also common, identified among 59 (20%; 95% CI 15.5–24.5%) women. Conclusions: The PHR is of low accuracy in relation to the recording of medications and ADRs. This warrants further research to examine the impact of these discrepancies on patient care and outcomes. The identification of strategies for improving the recording of information on medications and ADRs in the PHR is also required.