Abstract
Background and Objectives
Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio.
Methods
We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index.
Results
One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors.
Discussion
Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.
Introduction
Problem Description
Medication reconciliation errors are a widespread problem in health care. Medication reconciliation is defined as “a process of identifying the most accurate list of all medications a patient is taking including name, dosage, frequency, and route and using this list to provide correct medications for patients anywhere within the health care system.”1
A systematic review estimated that 67% of pediatric patients experience an error in their medication history during admission, while other studies have reported a range of medication admission errors in 22%–72.3% of patients.2,3 In addition, it has been noted that transitions of patient care are particularly hazardous for introducing medication errors, and prevalence of medical errors related to the discontinuity of care from the inpatient to the outpatient setting can be high (49%) and may be associated with an increased risk of rehospitalization.4 Medication reconciliation errors during discharge in a pediatric setting can range from 26% to 42.2% of discharges.5,6 Discharge medication errors can lead to drug adverse effects, patient and caregiver dissatisfaction, increase in phone calls and follow-up visits to the clinic, and a higher readmission rate.4,7
Dayton Children's Hospital (DCH) is a free-standing pediatric Hospital in Dayton, Ohio. The neurology department has an 8-bed Epilepsy Monitoring Unit and 10 subspecialty clinics. Patients admitted on the neurology service receive a postdischarge call within 1–2 days from our specialty neurology nurses. We noted that discharge medication reconciliation errors were a huge dissatisfier for our patients. During the follow-up calls, patients would express their angst about the medication errors made. The team had anecdotal feedback from patient advocates, community pediatricians, and others about the negative impact of discharge medication errors. We needed to institute long-term and sustainable interventions to decrease the rate of these errors.
Available Knowledge
Given the impact of medication reconciliation errors, The Joint Commission made medication reconciliation one of its National Patient Safety Goals in 2005. In 2011, the Center for Medicare and Medicaid services developed an Electronic Health Record (EHR) Incentive Program, which aimed to establish and demonstrate the meaningful use of certified electronic health record systems. Stage 2 of the EHR Incentive Program (renamed in 2022 to the Medicare Promoting Interoperability Program) includes medication reconciliation as a core objective.8,9
The American Academy of Pediatrics cites “miscommunication” and “improper documentation” as 2 of the top 10 reasons for medication errors in pediatric care.10 The Joint Commission identifies poor communication in transitions of care “as a cause of many medication errors.”11 Medication errors may be attributed to provider error and/or patient/caregiver misunderstanding and are particularly common in medications unrelated to the primary diagnosis.12
Although rare, medication errors can lead to potential adverse safety events for the patient. In our experience, errors to medications ordered during discharge has led to patient and/or caregiver dissatisfaction, confusion, and inefficient and additional time spent on reconciliation of medications for both the caregiver and neurology staff member.
The medication reconciliation error rate during discharge for patients admitted to the neurology service at Dayton Children's Hospital was 40% in 2018–2019 prompting initiation of this project. It is important to mention that errors during this period included prescriptions that had an incorrect expiration date on the electronic medical record (EMR) script accounting for an exaggerated error rate. The initial attempt to address this problem focused on increasing personnel by assigning pharmacists to the neurology service to review the medication reconciliation before discharge and asking attending physicians to complete their own discharge medication reconciliations. Education was also provided to bedside nursing staff on common order errors and nuances with the idea that they may be able to identify an error when reviewing the discharge paperwork with the family. These efforts while effective were not sustained because pharmacists were only available 1–2 days per week. The inpatient neurology service is very busy with 1 neurology physician covering both our Epilepsy Monitoring Unit and consult service. Adding an extra 15 minutes on an average for each patient's discharge medication reconciliation was not a sustainable option.
Rationale
This study follows the Standards for Quality Improvement Reporting Excellence reporting Guidelines 2.0 (SQUIRE 2.0).13 This project was a part of the Intermediate Quality Improvement Course (IQIC). We used the Institute for Healthcare Improvement QI methodology and Plan, Do, Study, and Act (PDSA) cycle interventions to address the medication reconciliation errors during discharge for patients admitted under the neurology service. We followed our hospital's quality improvement road map to test and implement lasting changes to our inpatient discharge process. The first step was to determine a specific aim, determine the measure, and identify the changes required. In the second step, we tested the changes through interventions and PDSA cycles. We used a simplified failure mode effect analysis (sFMEA) tool to understand the potential failure modes that were present. sFMEA is a systematic way to evaluate a process to identify where and how it might fail and to plan associated interventions to address those failures. We mapped the process and implemented interventions that articulated workflow in alignment with stakeholder expectations.10 We then prepared a Key Driver Diagram consisting of primary drivers, secondary drivers, and related change concepts or interventions.
It has been estimated that the entire process of medication reconciliation takes a median of 50 minutes per patient.14 We focused our interventions on improving communication between the neurology team and the pediatric residents who are responsible for medication reconciliation during discharge. After our first intervention, our baseline data showed that seizure rescue medications were the most common medication errors; we therefore devised a second intervention around education about seizure rescue medications to the pediatric residents and standardizing the order panels for rescue medications.
Specific Aims
Our SMART (specific, measurable, actionable, realistic, time-bound) aim was to reduce medication errors for neurology inpatients during discharge from a weekly average of 15.7% (7 errors/month) to less than 10% (4 errors/month). Errors were defined as either wrong medication, wrong dose, and wrong time or indication for use. The global aim was to improve safety, improve patient and caregiver satisfaction, and reduce lost time and financial resources.
Methods
Context
Before this project began, the discharge plan and medications were discussed during rounds verbally with the resident physician responsible for placing orders into the electronic medical record. The discharge orders and medication reconciliation often occurred after rounds and before completion of the encounter note by the neurologist, increasing the risk for misunderstanding and medication errors. The bedside nurse would then provide a written document with discharge medication instructions to the patient and family. One to 2 days post discharge, specialty neurology nurses perform a chart review on the plan provided to the family and perform a follow-up phone call. Discharge medication errors were identified during this phone call.
Intervention
Review of the sFMEA and development of the key driver diagram helped direct the development of the PDSA cycles. We tailored our interventions according to the secondary key drivers, which included clear communication, standardized rounding workflow, and efficient order panels (Figure 1).
Figure 1. The 2 Interventions Implemented With Corresponding PDSA Cycles.
Intervention 1, utilization of inpatient specialty neurology nurses to scribe the care plan and create a template note, and intervention 2, creation of seizure rescue medication order panels in the electronic medical record system. PDSA = plan, do, study, and act.
Scribed Rounding Summary/Written Plan of Care
The first intervention was developed in September 2021 and used the staff and resources currently available to the team. Our neurology inpatient care team consists of 1 physician (rotates weekly), resident physicians (varies by resident rotations), 3 inpatient specialty neurology nurses, and a floor nurse (all consistently). Social workers and pharmacists are available on a consultation basis.
The first intervention was divided into 3 PDSA cycles: development of a template to be included in the EMR note used during rounds for the specialty neurology nurse (PDSA cycle 1); utilization of the template on all neurology inpatients (PDSA cycle 2); and incorporation of seizure rescue medications with the dose and indication in the template (PDSA cycle 3). The template note included patient name, date, team members present, and scribed plan of care including details of medication dosing (Figure 2). The plan of care was formulated by the attending physician and scribed into the EMR by the specialty neurology nurse. The goal of this intervention was to improve communication within the neurology team and provide access to the written plan of care during order placement for the resident physician.
Figure 2. Neurology Template Note Implemented During Intervention #1 and Used During Inpatient Rounding.
Order Panel Development of Seizure Rescue Medications
A pareto chart identified incorrect prescription of seizure rescue medications as the most commonly occurring error accounting for 60% of all medication errors with 44% of these errors being an error in indication for use. Therefore, the second intervention was developed in January 2022 and included a focus on the development of a seizure rescue medication order panel. This intervention was divided into 3 PDSA cycles: development of a preference list with seizure rescue medications (PDSA cycle 1); development of instructions to use and access the preference list tailored to resident physicians (PDSA cycle 2), and development of an order panel of seizure rescue medications easily accessible to attendings and resident physicians (PDSA cycle 3). The order panel, titled “Discharge Seizure Rescue Medications,” included a list of all the medications that are commonly prescribed as seizure rescue medications, autopopulated route of administration (based on the medication chosen), and an autopopulated text for the indication for use (agreed upon by the neurology team) (Figure 3). The autopopulated fields reduce the chance for incorrect or omission of seizure rescue route of administration and indications for use. Education to the resident physicians regarding commonly prescribed seizure rescue medications and how to use the order panel was provided at each block of resident rotations by the specialty neurology nurses. The last PDSA cycle was initiated in October 2022.
Figure 3. Example of EPIC Order Panel of Seizure Rescue Medications Implemented During Intervention #2.
Measures
Medication errors were defined as an incorrect prescription of the following: medication, dose of medication, frequency, or timing of the dose. Each error was identified through chart review by the specialty neurology nurse 1–2 days post discharge. The error would be discussed and corrected in collaboration with the attending physician and communicated to the patient/family through phone call.
Medication errors were categorized by the neurology nurse practitioner using the National Coordinating Council for Medication Error Reporting and Prevention Index for Categorizing Medication Errors. Baseline data were collected from January 2021 through June 2021. Study data were collected from September 2021 through February of 2023.
Analysis
A control chart (P Chart) was selected to model outcomes, identify trends and/or shifts in the data, and to distinguish common vs special cause variation (Figure 4). Medication error rates were analyzed using statistical process control charts to identify data shifts and to distinguish common vs special cause variation. Shifts in data were based on the eight-point rule.15 The total error rate was calculated weekly as the number of errors made divided by the total number of patients discharged from the neurology inpatient service with prescribed medications.
Figure 4. P-Chart Displaying the Percentage of Medication Errors During Discharge for Patients Admitted to Neurology Service During the Baseline and Study Data Collection Period.
Standard Protocol Approvals, Registrations, and Patient Consents
This project was part of a quality improvement course offered by our hospital, and as such, Institutional Review Board approval was waived for this study.
Data Availability
Anonymized data not published within this article will be made available by request from any qualified investigator.
Results
Baseline data revealed an error rate of 15.7% or 7 errors per month. During the 26-month period of baseline and study data collection, a total of 106 errors were noted. Of these errors, 98 (92%) occurred in patients with seizures and 64 (60%) were related to prescription of seizure rescue medications, which included prescribing the wrong seizure rescue medication, the wrong dose, or the wrong indication for use. Incorrect indication for use accounted for 45% of the total number of errors. Reassuringly, none of the 106 errors resulted in patient harm; however, frustration to the families and the potential for loss of time and/or financial resources exist.
The first intervention—scribed rounding summary/written plan or care—revealed a shift in our data 8 weeks after initiation of this intervention reducing the average error rate from 15% (7 patients per month) down to 5.3% (2 patients per month). A seasonal variation affected our data with special cause variation noted during the winter holidays (December 2021) and during resident onboarding (July 2022) leading to the pursuance of the second intervention, which was initiated in January of 2022 with the last PDSA cycle being initiated in October of 2022.
After 10 weeks of implementation of the second intervention—order panel development of seizure rescue medications—there was a second shift in our data reducing the medication error rate further to 2.9% or 1 error per month. There were 10 consecutive weeks of 0% error rate (October 2022 through February 2023). During the 2022 winter holidays, there was no identified special cause variation.
Discussion
Discharge medication reconciliation errors are common in pediatrics and lead to patient and caregiver dissatisfaction and angst.5,6 The neurology division at DCH initiated a quality improvement project to address this problem. Previous attempts to address this could not produce sustainable results due to lack of availability of pharmacists and attending physicians to perform this task on a regular basis, so we decided to take a different approach.
The first intervention focused on creating a template of the plan of care with medication orders scribed by the specialty neurology nurses. The second intervention consisted on standardizing the seizure rescue medication order by creating an order panel including all the rescue medications presently available. We were able to achieve sustained improvement over a period of 18 months (approximately one and a half years) with a reduction in error rate from 15% (7 errors per month) to 3% (1 error per month).
There is evidence that pediatric neurology and hematology/oncology patients who are on polypharmacy are at a higher risk of medication errors.16 Epilepsy is one of the most common diagnoses for inpatient neurology admissions in pediatrics, and among these, anticonvulsant medication discrepancies are the most common cause of medication errors at admission.17
A study looking at children with medical complexity revealed that Onfi (clobazam) prescriptions were more likely to have medication order errors during the hospital stay.18 However, we did not find any study investigating the most common discharge medication errors in pediatric neurology. Thus, we used our hospital baseline data to target our interventions on seizure rescue medications.
Interventions to improve discharge medication reconciliation have focused on education during discharge and use of clinical pharmacists to reconcile medications during admission.19,20 Pharmacist involvement in hospital discharge transitions of care have had a positive impact on decreasing composite inpatient readmissions and ED visits in adult patients with moderately complex medication regimens.21
These interventions have highlighted the cost savings of pharmacist-led interventions for medication reconciliation.22 Automated health system–based communication to the Primary Care Physician and patient safety tools, including computerized discharge medication reconciliation, has also been used to decrease hospital discharge medication errors in medically complex patients.23
A systematic review investigating hospital-based medication reconciliation practices concluded that rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce, and available evidence supports using pharmacy staff and focusing on patients at high risk of adverse events.24
Our interventions did not add any cost to the hospital because we used the existing resources, namely our specialty neurology nurses, to implement the first intervention and the EMR order panel for the second intervention. Our approach to the problem is unique because we used nurses as facilitators of accurate communication within the care team. The fact that we have been able to consistently keep the discharge medication error rate at 3% indicates that these interventions are effective and sustainable.
There is potential for medication errors to be missed or overlooked when the specialty neurology nurse involved in the patient plan of care performed chart review. This is a single-center study, and therefore, our results may not be generalizable. In addition, our neurology inpatient care team may be unique to our hospital, and other institutions may not have the same resources of a specialty neurology nurse to conduct the next business day postdischarge phone calls.
Medication reconciliation errors during discharge can lead to drug adverse effects and patient harm. Using inpatient specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders can help decrease the discharge medication errors. These interventions do not add any additional cost to the hospital and have led to sustainable positive outcomes.
Acknowledgment
The authors acknowledge the cooperation and help of the nurses, medical staff, quality improvement team, and Intermediate Quality Improvement Course (IQIC) coaches of their institute.
Appendix. Authors
| Name | Location | Contribution |
| Sara Adducchio, CPNP | Department of Neurology, Dayton Children's Hospital | Drafting/revision of the article for content, including medical writing for content; major role in the acquisition of data; study concept or design; and analysis or interpretation of data |
| Ethan D. Grant, DPT | Department of Pediatrics, Wright State University Boonshoft School of Medicine | Drafting/revision of the article for content, including medical writing for content |
| Laura D. Fonseca, MS | Department of Neurology, Dayton Children's Hospital | Drafting/revision of the article for content, including medical writing for content |
| Abiodun Omoloja, MD | Department of Nephrology, Dayton Children's Hospital | Drafting/revision of the article for content, including medical writing for content |
| Gogi Kumar, MD | Department of Neurology, Dayton Children's Hospital; Department of Pediatrics, Wright State University Boonshoft School of Medicine | Drafting/revision of the article for content, including medical writing for content; study concept or design |
Study Funding
The authors report no targeted funding.
Disclosure
The authors report no relevant disclosures. Full disclosure form information provided by the authors is available with the full text of this article at Neurology.org/cp.
TAKE-HOME POINTS
→ We conducted a quality improvement (QI) project aimed to decrease discharge medication reconciliation errors for pediatric patients with epilepsy at Dayton Children's Hospital in Dayton, Ohio.
→ The QI project consisted of 2 interventions: using specialty neurology nurses to scribe the plan of care and creating order panels for all rescue medications presently available to facilitate accuracy of discharge medication orders.
→ The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention and further dropped to 2.9% after our second intervention.
→ These interventions do not add any additional cost to the hospital and have led to sustainable positive outcomes.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Anonymized data not published within this article will be made available by request from any qualified investigator.