Boarding Pass to Better Medication Delivery for Boarded Pediatric Emergency Patients

Prolonged boarding of patients in the pediatric emergency department (PED) is associated with increased risk of missed or delayed administration of essential home medications. Children with chronic medical or psychiatric conditions requiring time-sensitive medications may experience preventable clinical deterioration during extended PED stays. The aim was to increase the percentage of encounters in which all high-risk home medications were ordered for pediatric patients roomed in the PED for more than 4 hours from 38% to more than 70% between August 2024 and June 2026.

We conducted a quality improvement initiative at a large, academic PED. Eligible patients were aged 18 years or younger, remained in the PED for more than 4 hours after rooming, and were anticipated to require admission. Using Model for Improvement and Lean methodology, we implemented workflow-integrated interventions, including division-wide education, caregiver-integrated medication identification via electronic triage, time-based electronic reminders, and workflow-embedded ordering tools. The primary outcome was the proportion of encounters in which all high-risk home medications were ordered. Data were analyzed using statistical process control charts.

In association with our improvement interventions, the average percentage of encounters for boarding patients in which all high-risk home medications were ordered increased from a baseline of 38% to 87% with special cause variation observed on a statistical process control p-chart.

A multifaceted, workflow-integrated quality improvement initiative was associated with improved reliable ordering of high-risk home medications for boarded pediatric patients. Embedding medication identification and ordering supports within clinical workflows represents a scalable strategy to improve medication safety during prolonged PED stays.