Rationale:
The Ketogenic Diet (KD) is used to treat epilepsy and requires limitations of carbohydrate (CHO) intake to be effective. The Classic KD was developed with a small daily medication CHO allowance that is not calculated into the diet at or below 500 mg per day. Liquid and chewable medication often contain CHO well above this daily allowance. However, it remains unknown in what clinical settings and for which medications these prescribing errors occur.
Method:
A clinical decision support (CDS) within the inpatient electronic medical record (EMR) that alerts prescribers to high CHO medications was developed to reduce prescribing errors for KD patients. The prescriber, once alerted that a high CHO formulation is being ordered, can then change the order to a different formulation. Medication orders over a two-month period were reviewed to determine the location within the hospital where orders in error were placed, actual medications ordered in error, and dosing regimen for orders that triggered the high carbohydrate alerts.
Results:
Error alert triggering orders occurred 61 times in 16 different patients during the period of analysis. Only 13 of the 61 orders (21%) were on patients admitted to a designated neurology inpatient unit. Eighteen orders (30%) were placed on a general medical or a non-neurology specialty unit, 15 (25%) occurred in the inpatient rehabilitation unit, 11 (18%) occurred in the intensive care unit, 3 (5%) occurred in the Emergency Room, and 1 (1.6%) occurred in the operating room.
Sixteen of the 61 medications errors (26%) were for anticonvulsants: chewable phenytoin tablets(6), compounded zonisamide(4), levetiracetam liquid(4), lacosamide liquid(1), and compounded topiramate(1). Twenty-two errors (36%) occurred in scheduled non-neurology medications: acid suppression medications(4), gastrointestinal motility agents(4), cholecalciferol(3), montelukast(2), potassium citrate (2), calcium carbonate(2), furosemide(1), scheduled liquid acetaminophen(1), a multivitamin(1), a sleep aid(1), and an antibiotic suspension(1). Twenty-three errors (38%) were for medications prescribed for a single administration or for only as needed use. Most of these were pain medications: ibuprofen suspension(7), acetaminophen syrup(4), morphine sulfate(3), oxycodone(2), and gabapentin(1). There were also single doses of prednisolone and diphenhydramine.
Further analysis of CHO content of anticonvulsants and most frequently prescribed medications in error was performed and is presented in table 1.
Conclusion:
Medication errors in children on the KD pose a risk for excess CHO delivery from inappropriate mediation formulations. A CDS system embedded within the EMR identified only 21% of errors occur in designated in-patient neurology units. Most errors occurred in other areas of the hospital. The most common medication prescribing errors were for single dose and as needed pain medications. These are of special concern because of the very high CHO content of liquid acetaminophen and ibuprofen where a single dose can supply 10 to 80 times the daily medication CHO allowance for the KD. The other errors were for anticonvulsants or scheduled, mostly gastrointestinal medications. The most common anticonvulsant error occurred with levetiracetam where 2 times the daily allowance for CHO was ordered. Lower numbers of prescribing errors for the other liquid and compounded liquid anticonvulsants preparations were ordered that would have delivered 3 to 6 times the KD medication CHO allowances. Because of the high amounts of CHO in common childhood single dose and as needed medications, additional alerts and restrictions may be indicated.
Funding:
:FUNDING: This study was funded as part of the hospital system quality improvement process.
FIGURES
Figure 1