Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals

INTRODUCTIONMedication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicate...

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Published in:Pediatric quality & safety 2021-07, Vol.6 (4), p.e436-e436
Main Authors: Morse, Keith E., Chadwick, Whitney A., Paul, Wendy, Haaland, Wren, Pageler, Natalie M., Tarrago, Rod
Format: Article
Language:English
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Multi-institutional collaborative and QI network research
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Summary:INTRODUCTIONMedication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals. METHODSAn algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors. RESULTSThis study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors. CONCLUSIONThe presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.
ISSN:2472-0054
2472-0054
DOI:10.1097/pq9.0000000000000436