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Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and
Danielle D DeCourcey1, Melanie Silverman, Esther Chang
11Department of Medicine, Boston Children's Hospital, Boston, MA. 2Department of Pharmacy, Boston Children's Hospital, Boston, MA. 3Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, MA. 4Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA.
Insights
Potentially harmful medication errors are common in critically ill children with chronic conditions. Current medication reconciliation processes are insufficient to prevent these unintentional discrepancies.
Area of Science:
- Pediatric Critical Care Medicine
- Pharmacovigilance
- Patient Safety
Background:
- Medication reconciliation is standard during hospital admission.
- Unintentional medication discrepancies are a known cause of adverse drug events in adults with chronic illness.
- Rates of such discrepancies in pediatric intensive care are unknown.
Purpose of the Study:
- To determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease admitted to intensive care.
- To assess the adequacy of current medication reconciliation processes in this population.
Main Methods:
- Prospective observational cohort study.
- Consecutive sample of 308 patients (<25 years old) with chronic disease admitted to intensive and intermediate care units.
- Assessment of unintentional medication discrepancies with potential for harm, and associated patient/medication factors.
Main Results:
- 284 (10%) of 2739 medication discrepancies were unintentional and potentially harmful (0.9/patient).
- 45% were due to medication history errors, 55% to reconciliation errors; 66% occurred at admission, 45% were dosing errors.
- Increased risk associated with more preadmission medications, chronic respiratory medications, and noninvasive ventilation.
Conclusions:
- Potentially harmful unintentional medication discrepancies are common in critically ill children and young adults with chronic disease.
- Both medication history taking and reconciliation processes contribute to these errors.
- Current medication reconciliation processes are insufficient for this high-risk population.
Objectives:
Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease.
Design:
Prospective observational cohort study.
Setting:
Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014.
Patients:
Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization.
Measurements And Main Results:
The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy.
Conclusions:
Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.
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