Accuracy and Completeness of Medication Histories in Patients in Medical Admission Ward at the University Teaching Hospital

  • Melody Mutinta University of Zambia, School of Health Sciences, Department of Pharmacy, P.O. Box 50110, Lusaka, Zambia.
  • Lungwani Tyson Muungo 1. University of Zambia, School of Medicine, Department of Pharmacy,Lusaka,Zambia.
  • Pierre Yassa Cavendish University, School of Medicine, Lusaka, Zambia.
Keywords: Accuracy of medication history, complete medication history, medication history, Medication, Medication discrepancy


Background Quality documentation of medication histories at the time of hospitaladmission with regard to accuracy and completeness is notdocumented at the University Teaching Hospital (UTH), in Zambia. The aim of our study was to assess the accuracy and completeness of medication historiesobtained in patients upon hospital admission. Materials & Methods We conducted a prospective cross-sectional study atmedical admission ward, University Teaching Hospital, over a period of 3months. Our study enrolled 322 patients admitted to this ward who were above 18 years of age and were able to communicate verbally, ifnot, were accompanied by a caregiver. Clinical records of these patients were screened to review allmedications the patient was taking and patients/caregivers were interviewed to obtain acomplete medication history. All informationobtained from patients through interviews was compared withmedications recorded in the patient’s clinical records at the time ofadmission to the hospital. The Statistical Package for Social Sciences(SPSS) version 22 was used for all statistical calculations. Results Of 287 clinical records, 175 (61%) incidents of inaccurate medication historiesat the time of admission were identified and that medication histories in clinical records of patients were incomplete or poorly documented. Conclusion Our study shows that 61% of medication histories in patients at the time of admission to hospitals are inaccurate. Quality documentation of medication histories in clinical records at the time of hospital admission is poor.


Runciman WB, Roughead EE, Semple SJ, Adams RJ. Adverse drug events and medication errors in Australia.Int J Qual Health Care2003; 15(1);i49-i59
2. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R,Etchells EE.Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.CMAJ.2005; 173:510–5.
3. FitzGerald RJ. Medication errors: the importance of an accurate drug history.Br J ClinPharmacol. 2009; 67(6): 671–675.
4. Cockayne NL, Duguid M,Shenfield GM. Health professionals’ rarely record history of complementary and alternative medicines.Br J ClinPharmacol. 2005; 59(2); 254–258.
5. Vira1 T, Colquhoun M,EtchellsE.Reconcilable differences: correcting medication errors at hospital admission and discharge.QualSaf Health Care 2006; 15;122-126
6. Crook M, Ajdukovic M, Angley C, Soulsby N, Doecke C, Stupansi I,et al.Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist. Pharmacy Practice (Internet) 2007; 5(2) Redondela abr.
7. Unroe KT, Pfeiffenberger T, Riegelhaupt S, Jastrzembski J, Lokhnygina Y, Colon-Emeric C.Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J GeriatrPharmacother. 2010;8(2): 115–126.
8. Abu-Yassin BH, Aljadhey H, Al-Sultan M, Al-Rashed S,Adam M, Bates DW. Accuracy of the medication history at admission to hospital in Saudi Arabia.Saudi Pharm J 2011; 19(4); 263–267.
9. Hellström LM, Bondesson A, Höglund P, Eriksson T. Errors in medication history at hospital admission: prevalence and predicting factors.BMC ClinPharmacol. 2012; 12; 9.
10. Barnsteiner JH. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 38 Medication Reconciliation. Editor: Hughes RG. Apr 2008. Available from: (20th March 2014)
11. Cornish PL, Knowles SR, Marchesano R. Unintended medication discrepancies at the time of hospital admission. Arch. Intern. Med. 2005; 165(4); 424–429.
12. Greenwald JL, Halasyamani L, Greene J, LaCivita C, Stucky E, Benjamin B, Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant and Implementable: A Consensus Statement on Key Principles and Necessary First Steps.J Hosp Med.2010; 5(8) 477–485.
13. Yusuff K, Awotunde M. The frequency of drug history documentation in an institutionalized tertiary care setting in Nigeria.J Pharm Pharmaceut Sc.2005; 8(2); 141-146.
14. Gleason KM, Brake H, Agramonte V, Perfetti C.Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. Agency for Healthcare Research and Quality (AHRQ) 2012; 11(12) - 0059.
15. JCAHO. National Patient Safety Goals. 2005. Available from: (9th April 2014)
16. Accreditation program: hospitals. Oakbrook Terrace (IL): The Joint Commission; 2010, p. GL 19. National patient safety goals. Effective January 1, 2011. Available from: (9th April 2014)
17. Collins DJ, Nickless GD, Green CF. Medication histories: does anyone know what medicines a patient should be taking? International Journal of Pharmacy Practice. 2004; 12(4); 173–178.
18. Miller SL, Miller S, Balon J,Helling TS. Medication reconciliation in a rural trauma population. Ann Emerg Med. 2008; 52(5); 483–491.
19. Re`onja R, Knez L, Suskovic S, Kosnik M,Mrhar A.Comprehensive medication history: the need for the implementation of medication reconciliation processes. 2010;Original scientific article UDC 001.102:615.11:614.21
20. Carter MK, Allin DM, Scott LA,Grauer D. Pharmacist-acquired medication histories in a university hospital emergency department.Am J Health Syst Pharm.2006; 63(24); 2500-3.
21. Reeder TA, Mutnick A. Pharmacist- versus physician-obtained medication histories.Am J Health Syst Pharm. 2008; 65(9); 857-60
22. De Winter S, Spriet I, Indevuyst C, Vanbrabant P, Desruelles D, Sabbe M, et al. Pharmacist- versus physician-acquired medication history: a prospective study at the emergency department.QualSaf Health Care. 2010;19:371-375
How to Cite
Mutinta M, Muungo L, Yassa P. Accuracy and Completeness of Medication Histories in Patients in Medical Admission Ward at the University Teaching Hospital. Journal of Agricultural and Biomedical Sciences [Internet]. 28Jan.2021 [cited 23Apr.2021];4(4). Available from:
Biomedical Sciences