Authors :
Presenting Author: Sara Adducchio, MSN, CPNP-AC – Dayton Children's Hospital
Ethan Grant, DPT – Wright State University - Boonshoft School of Medicine; Laura Fonseca, MS – Dayton Children's Hospital; Gogi Kumar, MD – Dayton Children's Hospital
Rationale:
Medication reconciliation errors are a common problem in health care. Transitions of patient care are particularly hazardous for introducing medication errors. Medication reconciliation errors at the time of discharge in a pediatric setting can range from 26% to 42.2% of discharges.
Patients admitted on neurology service at Dayton Children’s Hospital (DCH) receive a follow up call from our inpatient nurse coordinators during which we identified discharge medication reconciliation (DMR) errors and their negative impact on the patients and the community primary physicians. We decided to institute long term and sustainable interventions to decrease the rate of these errors.
:
The initial interventions focused on assigning pharmacists to the neurology service to review the DMR prior to discharge as well as asking attending physicians to complete their own DMR. The positive results from these efforts were not sustained as pharmacists were only available one to two days per week and it was difficult for the attending physician to perform the DMR on a consistent basis. We collected baseline data from January 2021 through June 2021. A pareto chart was used to determine that the most frequently occurring errors were prescription of seizure abortive medications. We focused on improved communication of the care plan by utilizing the inpatient neurology nurse navigators as scribes. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order set for all the rescue medications presently available.
Medication errors were logged by the nurse navigator during a phone conversation 24 hours post-discharge. Error rate was calculated for each week using a control chart. Medication errors and patient harm was classified according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index.
Results:
Data was collected from January 2021 through February 2023. During this time, 106 errors were noted. Of these errors, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure abortive medication specifically.
The baseline error rate was calculated at 15.7% or seven errors per month (January 2021 through June 2021). Twelve weeks after initiation of the first Plan-Do-Study-Act (PDSA) cycle, we had a shift in our baseline reducing the error rate to 5.3% or two errors per month. The second PDSA was implemented in October 2022. Ten weeks after initiation of the second PDSA, there was another shift in data reducing the error rate further to 2.9% or one error per month. We had a sustained decrease in error rate to 2.9% errors per month for the last five months with a 10 week period of 0% errors (Figure 1). None of the errors resulted in patient harm.
Conclusions:
Utilizing inpatient nurse navigators to scribe the care plan and creating order sets to facilitate accuracy of discharge medication orders can help decrease the discharge medication errors in pediatric epilepsy patients. These interventions do not add any additional cost to the hospital and have led to sustainable outcomes.
Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.