Prevalence of medication discrepancies in pediatric patients transferred between hospital wards

Thaciana Dos Santos Alcântara1, Fernando Castro de Araújo Neto1, Helena Ferreira Lima1

  • 1Pharmaceutical Sciences Graduate Program, Laboratory of Teaching and Research in Social Pharmacy (LEPFS-UFS), Federal University of Sergipe, São Cristóvão, Brazil.

Insights

Pediatric medication errors are common during care transitions, especially at discharge. Omission of medication was the most frequent unintentional error found in this study.

Area of Science:

  • Pediatric Pharmacology
  • Patient Safety
  • Healthcare Transitions

Background:

  • Children face higher risks from medication errors and adverse drug reactions than adults.
  • Medication discrepancies during healthcare transitions contribute to these risks.
  • Lack of information and medication discontinuity are key contributing factors.

Purpose of the Study:

  • To determine the frequency of medication discrepancies at care transition points in a pediatric unit.
  • To analyze the types of medication discrepancies identified.

Main Methods:

  • A cross-sectional study was conducted in a pediatric department from August 2017 to March 2018.
  • Data included sociodemographic information, caregiver interviews, prescription review, and medical record evaluation.
  • Medication discrepancies were categorized as intentional or unintentional (omission, duplication, dose/frequency/route differences).

Main Results:

  • 85% of 114 pediatric patients experienced at least one unintentional medication discrepancy.
  • Discrepancies were most prevalent at hospital discharge (45.6%) and internal transfer (36.8%).
  • Omission of medication was the most common unintentional discrepancy, particularly at discharge (100%).

Conclusions:

  • Internal transfer and hospital discharge are critical points for unintentional medication discrepancies in pediatric care.
  • Medication omission is the predominant type of unintentional error, highlighting a significant patient safety concern.
  • Interventions targeting medication reconciliation at these transition points are crucial for improving pediatric patient safety.

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