Background In our hospital, the medication system is totally managed by computers. When physicians sign the computerised prescription, an electronic sheet must be completed for controlled antibiotics. In 2011, pharmacists created a specific second part on the sheet about re-evaluating the antibiotic. Physicians can complete it 72 hours after initiation of empirical treatments as indicated in the recommendations.
Purpose To evaluate the traceability of the re-evaluation of the antibiotic in the paper medical records and in the electronic antibiotics sheets. The results were compared with an audit conducted in 2010 of the re-evaluation in the paper medical records.
Materials and Methods An audit grid was created to assess the traceability of the re-evaluation, the changes of antibiotic treatment after re-evaluation and re-evaluation deadlines.
Results Of 50 medical records audited in the 5 hospital units, 12 were excluded because patients were hospitalised for less than 72 hours. 94.7% of empirical treatments were re-evaluated, 73. 5% of them before 72 hours (84% in 2010 and 90.7% of them before 72 hours). Physicians noted the re-evaluation in 58.3% of paper medical records (38.1% explicit re-evaluation, 61.9% implicit) versus 52% in 2010 (36.4% explicit re-evaluation, 63.6% implicit). 100% of electronic antibiotics sheets were completed: 25% by physicians and 75% by the pharmacist after calling the physicians. The re-evaluation led to treatment modification in 41.7% of the patients: change of the prescribed antibiotic (33.3%), change route of administration (26.7%), termination of treatment (20%), adding another antibiotic (20%).
Conclusions The rate of re-evaluation on paper medical records wasn’t significantly different to the result from a first audit conducted in 2010. Thanks to the pharmacists’ involvement, traceability on electronic sheets is being noted correctly. The results will be passed on to the hospital antibiotics committee. Improvements will be proposed for better multidisciplinary collaboration between bacteriologists, pharmacists and physicians.
No conflict of interest.
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