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Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals
Keith E Morse1, Whitney A Chadwick1, Wendy Paul2
1Division of Pediatric Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, Calif.
Introduction:
Medication 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.
Methods:
An 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.
Results:
This 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.
Conclusion:
The 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.
Insights
Medication reconciliation errors (MREs) are frequent in pediatric hospitals, affecting nearly half of discharges. This study identified 6 common MRE types to aid quality improvement efforts in reducing pediatric medication errors.
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.
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