BRITISH COLUMBIA – When children are admitted to the hospital, sometimes the
medications they take at home are lost in the shuffle, or they may be given the
system in place at hospital admission to record and review a child’s medication
history results in fewer errors, potentially avoiding harm to the patient, according to a study to be presented Monday,
May 5, at the Pediatric Academic Societies (PAS) annual meeting in Vancouver,
British Columbia, Canada.
Joint Commission, which accredits and certifies more than 20,000 health care
organizations in the United States, has set a patient safety goal to accurately
and completely reconcile medications as patients move through all health care
settings. The process involves comparing a patient's current medication regimen
against a physician's admission, transfer or discharge orders to identify
D. Hron, MD, FAAP, a pediatric hospitalist at Boston Children’s Hospital and an
instructor of pediatrics at Harvard Medical School, led a team that implemented
a quality improvement project that focused on reducing medication errors due to
breakdowns at hospital admission. A group of physicians, pharmacists, nurses
and information technology specialists worked together to test, implement and
train clinicians to use a tool, which facilitates review of a patient’s
complete medication history when the child is admitted to the hospital.
which is part of the hospital’s electronic health record system, was piloted in
one area of the hospital and gradually was expanded to the entire hospital. “We
successfully implemented the medication reconciliation application throughout
the hospital, changing the practice of our entire staff,” Dr. Hron said.
existing voluntary error reporting tool, Dr. Hron and his colleagues then looked
at the number of medication errors that occurred before and after
implementation of the electronic tool.
33,000 children were admitted to Boston Children’s Hospital during the study
period, and the medication reconciliation tool was used for 75 percent of
admissions after the intervention. The recording of medication history improved
from 89 percent of admissions before the tool was implemented to 93 percent of
admissions afterward. During the study, 146 medications errors due to missing or
incorrect information at admission were detected. The error rate decreased by
about 50 percent after hospital staff starting using the tool — from 5.9 errors
per 1,000 admissions to 2.5 errors per 1,000 admissions. Most of the errors did
not harm patients, while 1 percent required additional monitoring or
intervention but did not cause permanent harm.
medication reconciliation is essential to providing patient care, and it
requires teamwork between doctors, nurses and pharmacists,” Dr. Hron said. “If
it’s not being done in a systematic way, it’s not being done right.”
will present “Implementation of an Electronic Medication Reconciliation Tool
Results in a Reduction in Medication Errors” from 11:15-11:30 a.m. Monday, May 5.
To view the study abstract, go to http://www.abstracts2view.com/pas/view.php?nu=PAS14L1_3380.4.
outside funding was received for this research.
The Pediatric Academic
Societies (PAS) are four individual pediatric organizations that co-sponsor the
PAS Annual Meeting – the American Pediatric Society, the Society for Pediatric
Research, the Academic Pediatric Association, and the American Academy of
Pediatrics. Members of these organizations are pediatricians and other health
care providers who are practicing in the research, academic and clinical
arenas. The four sponsoring organizations are leaders in the advancement of
pediatric research and child advocacy within pediatrics, and all share a common
mission of fostering the health and well-being of children worldwide. For more information, visit www.pas-meeting.org. Follow news of the PAS meeting on Twitter at http://twitter.com/PedAcadSoc.