Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit

Area of Science:

• Pediatric Neurology
• Health Quality Improvement
• Medication Safety

Background:

• Discharge medication reconciliation (DMR) errors are prevalent in pediatrics, with rates from 26% to 42.2%.
• These errors pose significant risks, especially during care transitions for pediatric patients.
• A quality improvement project was initiated to address high DMR error rates at Dayton Children's Hospital.

Purpose of the Study:

• To decrease the discharge medication reconciliation error rate in pediatric patients.
• To implement and evaluate targeted interventions for improving medication accuracy upon discharge.
• To specifically reduce errors related to seizure rescue medications in epilepsy patients.

Main Methods:

• Two interventions were implemented using Plan-Do-Study-Act cycles over 19 months (September 2021 - February 2023).
• Intervention 1: Employed specialty neurology nurses as scribes with a standardized discharge care plan template.
• Intervention 2: Standardized seizure rescue medication orders via an electronic medical record order panel.

Main Results:

• The baseline DMR error rate was 15.7% (7 errors/month).
• Following Intervention 1, the error rate decreased to 5.3% (2 errors/month).
• After Intervention 2, the rate further dropped to 2.9% (1 error/month), with a subsequent 10-week period of 0% errors.

Conclusions:

• Sustainable reduction in pediatric DMR errors, particularly for epilepsy patients, was achieved.
• Utilizing specialty neurology nurses and electronic order panels effectively improved discharge medication accuracy.
• These interventions enhanced patient safety without incurring additional hospital costs.