Discharge Prescription Errors After the Implementation of a Prospective Pharmacist Review Process in a Pediatric...

Pediatric emergency department (ED) patients are at an increased risk for experiencing a preventable medication error. Studies show that pharmacists are effective at decreasing medication errors on inpatient orders but there are few studies looking at error reduction on discharge prescriptions. Children's Health implemented a prospective pharmacist verification process on all ED discharge prescriptions. The objective of this study is to identify and describe the prescription errors leaving a pediatric ED after the implementation of this pharmacist review process.

An electronic medical database was utilized to identify all ED prescriptions between January 1, 2016, and June 30, 2016. A random number generator was used to select 750 prescriptions. Two pharmacists independently performed a chart review assessing prescriptions for errors. A third pharmacist was used to clarify discordant assessments between the 2 pharmacists. Errors were recorded and assessed for severity using the Taylor et al 2005 stratification. The primary objective of this study is to identify the errors leaving the ED. Secondary objectives include: error severity, error subtype, and readmission rates.

Forty-one errors were identified from 750 randomly selected prescriptions for a total error rate of 5.5%. The most common subtypes of errors were missing duration (39%) and antimicrobial optimization (24.4%). When using the Taylor et al 2005 scale, no prescriptions were classified as severe or serious. None of the errors led to patient harm.