Admission Medication Reconciliations in Pediatric Patients Admitted to an Inpatient Psychiatry Unit

Abstract

OBJECTIVE

Medication errors resulting in adverse drug events may occur during transition of care. Most can be prevented with a medication reconciliation. California Senate Bill 1254 requires a pharmacist to perform an admission medication reconciliation (AMR) to obtain an accurate medication list for each high-risk patient upon hospital admission. Adult patient literature reveals that antidepressant, antipsychotic, and mood-stabilizing drugs are high-risk medications likely to cause errors. Therefore, the purpose of this analysis is to determine if pediatric psychiatry inpatients should be considered high risk, meriting an additional AMR by the pharmacy team.

METHODS

This was a retrospective, single-center analysis of pediatric patients admitted to the inpatient psychiatry unit at Rady Children's Hospital, San Diego between January 1 and 31, 2021. All newly admitted patients had an AMR performed by the medical team (physician-led AMR). High-risk patients (prescribed a high-risk medication or 3 or more medications of any kind prior to admission) had an additional AMR by the pharmacy team (pharmacy-led AMR). Differences between these 2 AMRs were examined.

RESULTS

Of the 58 patients admitted during the study period, 39 (67.2%) were identified as high risk, warranting an AMR by the pharmacy team. From the 170 medications reviewed, 51 differences (30%) were found between physician-led and pharmacy-led AMR, with 4 (2.4%) of the differences involving high-risk medications. No medications were incorrectly ordered, and no adverse drug events occurred.

CONCLUSIONS

Given that physician-led and pharmacy-led AMRs of high-risk prescription medications were only marginally different and no medications were incorrectly ordered, the existing AMR methodology used by psychiatrists at our institution is effective at creating a safe medication list.

Introduction

Medication errors and discrepancies tend to occur during transitions of care when medications are started or continued.¹ The National Coordinating Council for Medication Error Reporting and Prevention defined a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer.”² A study at Mayo Eugenio Litta Children's Hospital in Rochester, Minnesota, demonstrated that 92% of medication reconciliation (MR)–related interventions occurred during admission medication reconciliation (AMR) and that the most frequent type of errors was the omission of home medications.³

Most adverse drug events from medication errors are preventable by completing an MR at the various points of transition of care: admission, transfer, and discharge.¹ Recognized as a National Patient Safety Goal (NPSG 03.06.01), MR is the process of creating the most current and accurate medication list possible for a patient and then comparing it against the medication list that is prescribed for the patient at the time of transition of care.^1,4 The ideal MR should be complete, including the name, formulation, and strength of both prescription and over-the-counter (OTC) medications, as well as the dose, prescribed directions for frequency and route of administration, and the patient's adherence to the regimen.

Passed in September 2018, California Senate Bill 1254 (SB 1254) requires a pharmacist at all California hospitals to “obtain an accurate medication profile or list for each high-risk patient upon admission,”⁵ and requires the hospital to “establish the criteria regarding who is a high-risk patient,” but offers no guidance and leaves defining “high risk” to each individual hospital.⁵ Studies regarding medication errors and reconciliations are well established for adult patients but are still lacking for the pediatric population.⁶ As a result, most children's hospitals have limited standards for reference when trying to establish criteria for determining which patients should appropriately be designated high risk.⁶ Adult patient literature reveals that antidepressant, antipsychotic, and mood-stabilizing drugs are high-risk medications likely to cause medication errors.^7,8 Therefore, the purpose of this analysis is to determine if pediatric psychiatry inpatients should be considered high risk, meriting an additional AMR by the pharmacy team.

Materials and Methods

This was a retrospective, single-center analysis of pediatric patients admitted to the Child and Adolescent Psychiatry Services (CAPS) unit at Rady Children's Hospital, San Diego (RCHSD), California between January 1 and 31, 2021. All patients admitted to the CAPS unit within this time frame were reviewed. Patients included in our analysis had one or more home medications prior to admission (PTA) and had an AMR performed by the pharmacy team as indicated by a Consulting Progress Note and iVent in their electronic health record. Consulting Progress Note and iVent are both features used by pharmacy staff to document patient care within Epic, the electronic health record system at RCHSD.

All patients admitted to RCHSD had an AMR performed by the medical team (physician-led AMR). High-risk patients received an additional AMR by the pharmacy team (pharmacy-led AMR). High-risk patients were defined as patients with 3 or more prescription medications PTA or taking 1 or more of the following high-risk medications: antiepileptic, anticoagulant, antiplatelet, antidiabetic (including oral and injectable agents), antidepressant, antipsychotic, or mood-stabilizing drugs. The pharmacy-led AMR was a 3-step process. First, a medication list was obtained from the patient/caregiver and outpatient pharmacies, and, when available, from Surescripts as well. Surescripts is a feature in Epic that reports the patient's medication refill history. Next, this medication list was compared to the list obtained by the medical team. Lastly, working with the medical team, errors, if any, were identified, and an updated medication list was established. This process was applied to any patient admitted to the CAPS unit who met our inclusion criteria.

Clinical data and demographics including patient age, adherence, total number and classes of medications reviewed, and types of differences between physician-led and pharmacy-led AMR were collected. Types of medications reviewed included OTC vs prescription medications. Prescription medications were further categorized into high-risk medications, which included antiepileptic, anticoagulant, antiplatelet, antidiabetic, antidepressant, antipsychotic, and mood-stabilizing drugs. Types of differences found were omissions (medications taken at home that were omitted from the AMR list), medications no longer being taken (but were still included on the AMR), and differences in dose, strength, frequency, or formulation of a medication.

Descriptive statistics (median, IQR, counts, and percentages) and flowcharts were used to describe patient demographics and the differences found between physician-led and pharmacy-led AMR.

Results

In this study, of the 58 patients that were admitted during the time frame, 39 (67.2%) were identified as high risk and received an additional AMR by the pharmacy team. Patient demographics and baseline characteristics are listed in Table 1. Of the 39 patients with a pharmacy-led AMR, 24 (61.5%) had 3 or more medications PTA, 31 (79.5%) had 1 or more high-risk medication PTA, and 23 (59%) had both 3 or more medications PTA and 1 or more high-risk medications. A total of 29 (74.4%) of the patients were adherent to their medications, which was defined in this study as missing no more than 2 doses within the week prior to admission. Two of the 39 high-risk patients had a readmission within the time frame.

Table 1.

Patient Demographics (N = 39)

Characteristics	Results
Age, median (IQR), yr	14 (7–17)
≥3 medications PTA, n (%)	24 (61.5)
≥1 high-risk medication PTA, n (%)	31 (79.5)
≥1 high-risk and ≥3 medications PTA, n (%)	23 (59.0)
Adherent: ≤2 missed doses within the week prior to admission, n (%)	29 (74.4)
Readmission within the same month, n	2

PTA, prior to admission

A total of 170 medications were reviewed from the 39 patients' AMRs (Supplemental Figure 1). Of the 170 medications reviewed, 54 (31.8%) were OTC medications and 116 (68.2%) were prescription medications. The 116 prescription medications consisted of 61 (35.9%) high-risk medications, which included 3 (1.8%) antidiabetic, 9 (5.3%) antiepileptic, and 49 (28.8%) antidepressant, antipsychotic, or mood-stabilizing drugs.

Of the 170 medications reviewed, there were 51 (30%) differences between physician-led and pharmacy-led AMR (Supplemental Figure 2). The 51 differences consisted of 8 (4.7%) differences in the dose, strength, frequency, or formulation of the medication, 32 (18.8%) omissions, and 11 (6.5%) medications no longer taken. The 8 differences in dose, strength, frequency, or formulation of the medication involved 5 (2.9%) OTC and 3 (1.8%) prescription medications, with only 1 of those 3 (0.6%) being a high-risk medication. Of the 32 medications omitted from the AMR, 25 (14.7%) were OTC medications and 7 (4.1%) were prescription medications, with none of the 7 being a high-risk medication. The 11 medications no longer taken included 3 (1.8%) OTC and 8 (4.7%) prescription medications, with 3 (1.8%) of those 8 being high-risk medications. The medications with the most differences were OTC melatonin and multivitamin.

Of the 51 medication differences, 4 (2.4%) involved a high-risk medication (Table 2). One (0.6%) was a difference in the dose of escitalopram reported in the AMR compared with the dose the patient was currently taking. The other 3 (1.8%) were medications that patient was no longer taking but were not removed from the AMR: trazodone, venlafaxine hydrochloride extended-release and glargine. No medications were incorrectly ordered, and no adverse drug events occurred.

Table 2.

Differences Between Pharmacist-led and Physician-Led AMR in High-Risk Medications Only

Differences	Frequency, N (%), n = 51
Medication differences in dose, strength, frequency, or formulation	1 (1.6)
Dose	1 (1.6)
Strength	0 (0)
Frequency	0 (0)
Formulation	0 (0)
Medications omitted from PTA list	0 (0)
Medications removed from PTA list	3 (4.9)

AMR- Admission Medication Reconciliation; PTA, prior to admission

Discussion

Given the lack of pediatric AMR studies, children's hospitals have limited resources and guidance to establish the criteria for high-risk patients who would require an additional AMR by pharmacy in compliance with SB 1254. Adult studies have shown that high-risk medications likely to cause medication errors and adverse drug events include anticoagulant, antiplatelet, antidiabetic, antiepileptic, antidepressant, antipsychotic, and mood-stabilizing drugs.⁷ As a result, this study evaluated whether pediatric patients admitted to a psychiatry unit should be considered as high-risk patients, meriting a pharmacy-led AMR in addition to the physician-led AMR that is performed on all newly admitted patients. Results from this study may help hospitals with limited pharmacy medication reconciliation resources to better develop criteria for their high-risk patients and, when necessary to comply with SB 1254.

It should be noted that the medication differences between physician-led and pharmacy-led AMR may be undercounted given that multiple differences for a single medication are counted as only 1 difference. For example, if a medication on the AMR had a difference in both dose and frequency, this was just counted as 1 difference. In addition, medications that had the most differences were OTC melatonin and multivitamin. This may have been due to the physicians putting less emphasis on reconciling these particular medications during AMR, given that patients admitted to the unit, when appropriate, will be ordered a partially standardized set of “as needed” medication and/or supplements that often includes melatonin (a one-time “as needed” dose that is only continued if the parents consent) and a multivitamin.

Limitations of this study included the relatively small sample size, the 1-month time frame for data collection, and a single study site. Thus, these results may not be representative of year-round practices, and could differ from hospitals in other states. In addition, the results may not be applicable to patients with antidepressant, antipsychotic, or mood-stabilizing medications on their PTA list admitted to units other than our psychiatric in-patient unit. This is because in our unit, psychiatrists are performing the AMR, whereas in other non-psychiatric units, this is not typically the case. Thus, the accuracy of the physician-led AMR involving antidepressant, antipsychotic, or mood-stabilizing medications may be higher in our specialized psychiatric unit than in other medical units. Future directions for this study could include multiple study sites throughout the nation and a year-long time frame for data collection to provide nationally representative results.

Conclusion

In this study, 51 (30%) medication differences were found between physician-led and pharmacy-led AMR. Of these, only 4 (2.4%) involved high-risk medications (3 antidepressants and 1 antidiabetic). This demonstrated that the current AMR process conducted by the pharmacy created the most complete medication list for a patient. However, given that physician-led and pharmacy-led AMRs of high-risk prescription medications were only marginally different, no medications were incorrectly ordered, and no adverse drug events occurred, the current AMR methodology by the psychiatrists is effective at creating a safe medication list. As a result, patients admitted to a psychiatry unit where AMR is performed by a psychiatrist may not warrant an additional AMR by pharmacy. Additionally, psychiatric medications could potentially be excluded from the high-risk criteria. However, studies replicating this result on other pediatric psychiatry units as well as studies examining risk in psychiatric medication AMR on non-specialized pediatric medicine units are needed.

ABBREVIATIONS

AMR

admission medication reconciliation

CAPS

Child and Adolescent Psychiatry Services

MR

medication reconciliation

OTC

over the counter

PTA

prior to admission

RCHSD

Rady Children's Hospital, San Diego