[3380.4] Implementation of an Electronic Medication Reconciliation Tool Results in a Reduction in Medication Errors

Jonathan D. Hron, Shannon Manzi, Vincent W. Chiang, Marcie Brostoff, Stephanie A. Altavilla, Marvin B. Harper. Medicine, Boston Children's Hospital, Boston, MA; Pharmacy, Boston Children's Hospital, Boston, MA; Clinical Education and Informatics, Boston Children's Hospital, Boston, MA.

BACKGROUND: Medication reconciliation is a Joint Commission National Patient Safety Goal and electronic medication reconciliation is a menu item for Meaningful Use.
OBJECTIVE: We sought to measure the impact of implementation of an electronic medication reconciliation tool on observed admission medication reconciliation errors at a pediatric hospital.
DESIGN/METHODS: An electronic tool for hospital admission medication reconciliation was introduced at our single, tertiary care children's hospital from November 2011 to June 2012. This tool within the electronic health record encourages active medication reconciliation by displaying pre-admission medications on the left side of a split screen, allowing the user to manipulate the list to generate admission medication orders on the right. Reporting tools were developed to provide daily feedback if reconciliation was not performed. A pre-existing Safety Event Reporting System was used to identify medication safety events, which were classified as related, or not related, to medication reconciliation. Error rates for the pre-intervention and post-intervention periods were compared.
RESULTS: During the study period there were 33,070 hospital admissions. The medication reconciliation tool was used for 75% of admissions in the post-intervention period. Pre-intervention to post intervention medication history recording improved from 89% to 93% of admissions. During the study 146 admission medication reconciliation errors were detected. The rate of errors decreased from 5.9 errors per 1000 admissions pre-intervention to 2.5 errors per 1000 admissions post intervention (58% reduction; p = 0.028). Medication reconciliation errors were categorized as near miss (35%), reached the patient but resulted in no harm (42%), resulted in a minor transient change in condition (22%), or resulted in a transient change in condition that required monitoring or additional intervention (1%). No error required patient resuscitation, ICU transfer or resulted in permanent harm.
CONCLUSIONS: The implementation of an electronic tool for medication reconciliation was associated with a significant decrease in the number of reported admission medication reconciliation errors in a pediatric population. These findings support ongoing national efforts related to medication reconciliation to improve patient safety and the role of the tools used.


Session: Platform Session: General Pediatrics: Data Driven Change (10:30 AM - 12:30 PM)
Date/Time: Monday, May 5, 2014 - 11:15 AM
Room: East 12 - Vancouver Convention Centre
Course Code: 3380


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