Decreasing Prescriber Errors in a Tertiary Care Pediatric Intensive Care Unit via QI Methodology

Medication errors are a significant source of preventable adverse drug events for pediatric patients, particularly those with a complex chronic condition (CCC). In our pediatric intensive care unit (PICU), medication errors often occurred during admission or as medication regimens were adjusted throughout hospitalization. Our primary aim was to reduce the rate of reported prescriber medication errors per 1,000 medication orders by 40% between August 2022 and June 2024.

Key drivers contributing to prescriber medication errors included the lack of a standardized medication reconciliation process, high-risk medications unintentionally expiring, and the difficulty of reconciling the home medication list for patients with a CCC. Five plan-do-study-act interventions were completed. A retrospective chart review was used for all baseline data. The primary outcome was the rate of reported monthly prescriber medication errors per 1,000 medication orders placed. This project took place in a 26-bed PICU within an urban, tertiary care children's hospital.

The rate of reported prescriber medication errors remained stable throughout the intervention period without evidence of special cause variation. However, admission medication reconciliation errors among children with CCCs decreased by a mean of 43% over time, with a downward centerline shift.

A multidisciplinary quality improvement approach was associated with improvement in medication reconciliation processes for children with CCCs. Pharmacy-supported medication reconciliation and standardized workflows were associated with fewer admission medication reconciliation errors in this high-risk population.