Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals.

Area of Science:

• Pediatric Healthcare
• Medication Safety
• Quality Improvement

Background:

• Medication reconciliation errors (MREs) are prevalent and can cause patient harm.
• Current methods for identifying MREs, like chart reviews, are resource-intensive.
• Hospital-wide quantification of MREs is challenging.

Purpose of the Study:

• To define 6 easily identifiable MREs for organization-wide detection.
• To determine the prevalence of these MREs in two pediatric hospitals.

Main Methods:

• Algorithmic analysis of discharge medication lists.
• Clinician reviewer confirmation of identified errors.
• Focus on 6 specific error types: Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions.

Main Results:

• Analysis of 67,339 discharge medications across two pediatric hospitals.
• Institution A: 29.9% of discharges had errors (0.7 errors/discharge).
• Institution B: 42.2% of discharges had errors (1.6 errors/discharge).
• Duplication and See Instructions errors were most common.

Conclusions:

• The defined MREs are common in pediatric care.
• This method provides a tool for hospital-wide quality improvement to reduce pediatric medication errors.