Reducing Medication Reconciliation Errors: Improvement Initiative in an Academic Children’s Hospital

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Medication errors are estimated to result in more than 400,000 preventable adverse drug events per year. Factors such as medical complexity, weight based dosing, and off label use of medications in children, increases the susceptibility of children to harm from medication errors and adverse drug events. Medication reconciliation provides an opportunity to prevent medication errors and has been recognized by national organizations as a national patient safety goal to reduce the number of hospital medical errors. However, patient safety continues to be at risk if medication reconciliation is inaccurate especially during transitions of care. Review of patient safety events from 2020 to 2021 at an academic children’s hospital identified a total of 71 medication errors due to inaccurate medication reconciliation. The most common errors identified were errors in medication dosage and inaccurate route of medication administration.

To identify the challenges associated the medication reconciliation process, an eight-question survey was administered to 60 pediatric residents in March 2020 with the goal of implementing interventions to reduce medication reconciliation associated errors. The response rate from the survey was 43%. Summary of key challenges were inefficiencies with the electronic health record, pager-related interruptions, lack of standardized medication reconciliation process, lack of knowledge of medication reconciliation process, caregiver lack of medication knowledge, and lack of medication reconciliation during transition of care between units or care teams. Targeted interventions implemented during the 2021- 2022 academic year include pharmacy and clinical informatics team education on medication reconciliation, published job aids with use cases and a published list of common medication substitutions. Given significant barriers such as the COVID-19 pandemic, limited staff support, and resident turnover a post intervention survey was unable to be conducted.



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