Summary of main findings for unintended variances
| Overall(N = 60) | Admission(N = 60) | Discharge(N = 56) | |
|---|---|---|---|
| No of patients with at least one unintended variance (%, 95% CI) | 36 (60%, 48 to 72) | 23 (38%, 26 to 51) | 23 (41%, 28 to 54) |
| Mean number of unintended variances per patient (95% CI) | 2.3 (1.5 to 3) | 1.2 (0.7 to 1.6) | 1.2 (0.7 to 1.7) |
| Types of unintended variances (% of variances) | |||
| Total number of unintended variances | 136 (100%) | 69 (100%) | 67 (100%) |
| Omitted medication/prescription | 80 (59%) | 50 (72%) | 30 (45%) |
| Incorrect/omitted details (dose, route, frequency) | 18 (13%) | 15 (22%) | 3 (4%) |
| Additional medication unintentionally ordered | 4 (3%) | 4 (6%) | 0 |
| Lack of discharge instruction regarding medication changed in hospital | 34 (25%) | NA | 34 (51%) |
| No of patients with at least one clinically important unintended variance (%, 95% CI) | 11 (18%, 9 to 28) | 9 (15%, 6 to 24) | 5 (9%, 2 to 16) |
| Clinically important unintended variances | 20 | 10 | 10 |
| Intercepted | 15 | 8 | 7 |
| Not intercepted | 5 | 2 | 3 |
| Variances leading to harm | 4 | 2 | 2 |
| Physician response to unintended variance | |||
| Order new medication/prescription | 21 (15%) | 2 (3%) | 19 (28%) |
| Discontinue or hold medication | 3 (2%) | 1 (1%) | 2 (3%) |
| Change details (e.g. dose, route, frequency) | 11 (8%) | 7 (10%) | 4 (6%) |
| Restart medication | 31 (23%) | 22 (32%) | 9 (13%) |
| No changes made | 70 (51%) | 37 (54%) | 33 (49%) |
| Total | 136 | 69 | 67 |