Anna Yang, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Christine D.. Franciscovich, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Ursula S. Nawab, CHOP, Philadelphia, PA, United States; Meghan Galligan, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
Hospitalist Childrens Hospital of Philadelphia Philadelphia, Pennsylvania, United States
Background: Medication errors are a common source of preventable harm to hospitalized pediatric patients. As part of a large, interprofessionalsafetyinvestigation, we reviewedmedication errors occurring in association with inpatient consultationby subspecialty teams.We analyzed contributing factors and identifiedthat variable transmission of written medication information from consulting to primary teamswas a potential vulnerability contributing to these errors. Objective: We aimedtocharacterize the quality of medication recommendationsdocumented by subspecialty consult teams, with a broader goal ofguidingimprovement efforts targeting medication safety. Design/Methods: We used chart review to analyzedocumentationfrom 3 subspecialty teams at our hospital over a 13-month period (September 2021-October 2022). We analyzed medication recommendations contained in the assessment and plan at initial consultation. If a plan contained recommendations for ≥1 medication, we analyzed each for quality. ‘High quality’ recommendationswere defined as thosethat addressed each of the following elements:dose, frequency, route, indication, and duration. We accounted for any referenceto these elements (e.g., ‘duration unknown’ was considered a reference to duration). We derived this definitionfromcommon medication safetystandards(e.g., 6 rights of medication administration) and from feedback from stakeholder partners (e.g., medication safety leaders and subspecialty physicians). Results: We analyzeda total of 347 consult notes for 342 unique patients, including 179 (51%)from Team 1; 92(27%)from Team 2, and 76 (22%)from Team 3. Of 347 notes, 126 (36%)containedrecommendations for ≥1 medication, with an average of 1.4 medications per note.Of 178 total recommendations, a mean of 15% weredefined ashigh quality (Figure 1).Documentationvaried across teams and medication components, but route was a common omission(Figure 2).
Conclusion(s): Documentation of medication recommendations among inpatient consultants poses a potential vulnerability to medication safety. In this study, we found that only 15% of specialty medication recommendationscontained all components of a complete medication recommendation. Future work will pilot interventions to improve documentation quality with a broader goal of reducing medication errors.
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