Objectives: Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease.
Design: Prospective observational cohort study.
Setting: Patients discharged from the intensive and intermediate care units at a tertiary care children’s hospital from September 2013 to May 2014.
Patients: Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization.
Measurements and Main Results: The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04–1.10]), chronic respiratory medications (1.51 [1.01–2.28]), and chronic noninvasive ventilation (1.53 [1.07–2.19]) were associated with increased risk of a discrepancy.
Conclusions: Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.
1Department of Medicine, Boston Children’s Hospital, Boston, MA.
2Department of Pharmacy, Boston Children’s Hospital, Boston, MA.
3Center for Patient Safety and Quality Research, Boston Children’s Hospital, Boston, MA.
4Department of Population Medicine, Harvard Pilgrim Health Care Institute, Boston, MA.
Dr. DeCourcey conceptualized and designed the study, drafted the initial article, approved the final article as submitted. She had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ms. Silverman supervised the data collection, carried out the initial analyses, wrote the methods section, reviewed and revised the article, and approved the final article as submitted. Dr. Chang took the medication histories and completed all of the reconciliations and initial error evaluation, reviewed and revised the article, and approved the final article as submitted. Dr. Ozonoff carried out all of the secondary analyses and statistical modeling, wrote the statistical analysis section, reviewed and revised the article, and approved the final article as submitted. Dr. Stickney performed the medication adjudications, reviewed and revised the article, and approved the final article as submitted. Ms. Pichoff performed the medication adjudications, reviewed and revised the article, and approved the final article as submitted. Ms. Oldershaw designed the data collection instruments, coordinated and supervised data collection, and approved the final article as submitted. Dr. Finkelstein participated in study design, data analyses, reviewed and revised the article, and approved the final article as submitted.
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Supported, in part, by the Program for Patient Safety and Quality at Boston Children’s Hospital and by the National Institutes of Health T32 HD 75727: Research Training in Prevention and Care of Chronic Illness in Childhood.
Drs. DeCourcey and Finkelstein’s institution received funding from National Institutes of Health (NIH) T32 HD 75727: Research Training in Prevention and Care of Chronic Illness in Childhood and from Program for Patient Safety and Quality at Boston Children’s Hospital, and they received support for article research from NIH. Ms. Oldershaw’s institution received funding from PPSQ grant internal to Boston Children's Hospital. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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