Epidemiology of medication discrepancies upon hospital admission in children - a systematic review

Objectives: NICE/NPSA excluded children under 16 from their guidance concerning medicines reconciliation (MR) upon admission.1 Our aims and objectives of conducting the literature review was to identify the epidemiology of medication discrepancies upon admission, transfer and discharge in children, and if they require MR. Method: Six bibliographical databases (Medline, Embase, CINAHL, International Pharmaceutical Abstracts, Web of Science and Biosis Previews) and selected key words were used to find epidemiological studies on medication discrepancies in children upon hospital admission, transfer and discharge (key words included ‘medication discrepancy’; ‘medication reconciliation’; ‘hospital admission’; ‘hospital discharge’; ‘hospital transfer’); studies where the data for children could be extracted were included. Results: From the 1239 articles found (in May 2011), eight of the articles had extractable paediatric information, (five from Canada, two from USA, one from UK). Five of the studies involved discrepancies on admission, one involved discrepancies on admission and transfer, one involved discrepancies at transfer and one considered discharge. The reference point used to compare against the admission, transfer and the discharge order differed in each of the studies. Four studies used a rating scale to assess the clinical significance of the discrepancies to demonstrate the potential adverse clinical outcome of patients in the absence of clinical intervention. Two studies2 3 used a rating scale that was used in adults.4 A study of paediatric neurosurgical patients found that initial hospital prescriptions for children differed from the preadmission prescriptions in 39% of occasions and 50% of all prescribing variations had the potential to cause moderate or severe discomfort or clinical deterioration.2 A study by Coffey et al in general paediatric admissions in Canada showed 22% of patients experienced at least one discrepancy and 29% of the discrepancies had the potential to cause moderate or severe discomfort or clinical deterioration.3 By comparison an epidemiological study in discrepancies in adults on admission had 38.6% of the discrepancies identified with a potential to cause moderate or severe discomfort or clinical deterioration.4 All the studies involved small samples or specific patient groups such as medically complex patients. However all of the studies demonstrated that discrepancies occurred among paediatric populations during transitions in care settings and mentioned MR as an intervention. Conclusion: The results have shown that discrepancies of medication upon hospital admission, transfer and discharge occur regularly in children. With only one published study in the UK looking at hospital admission in children, and no published articles on the incidence and epidemiology of medication discrepancies upon hospital transfer or discharge further research is required in a wider paediatric population. Further work is also required to define the required interventions to improve practice.

The clinical significance of medicines reconciliation in children admitted to hospital

Aims and Objectives: The NICE/NPSA guidance on Medicines Reconciliation in adults upon hospital admission excludes children under the age of 16.1 Hence the primary aim and objective of this study was to use medicines reconciliation to primarily identify if discrepancies occur upon hospital admission. Secondary objectives were to clinically assess for harm discrepancies that were identified in paediatric patients on long term medications at four hospitals across the UK. Method: Medicines reconciliation is a procedure where the current medication history of a patient prior to hospital admission would be taken and verifying the medication orders made at hospital admission against this history, addressing any discrepancies identified. Medicines reconciliation was carried out prospectively for 244 paediatric patients on chronic medication across four UK hospitals (Birmingham, London, Leeds and North Staffordshire) between January – May 2011. Medicines reconciliation was conducted by a clinical pharmacist using the following sources of information: 1) the patient's Pre-Admission Medication (PAM) from the patient's general practitioner 2) examination of the Patient's Own Medications brought into hospital, 3) a semi-structured interview with the parent-carers and 4) identification of admission medication orders written on the drug chart prior to clinical pharmacy input (Drug Chart). Discrepancies between the PAM and Drug Chart were documented and classified as intentional or unintentional. Intentional discrepancies were defined as changes that were made knowingly by the prescriber and confirmed. Unintentional discrepancies were assessed for clinical significance by an expert panel and assigned a significance score based on the likelihood of causing potential discomfort or clinical deterioration: class 1 unlikely, class 2 moderate and class 3 severe.2 Results: 1004 medication regimens were included from the 244 patients across the four sites. 588 of the 1004 (59%) medicines, had discrepancies between the PAM and Drug Chart; of these 36% (n = 209) were unintentional and included for clinically assessment. 189 drug discrepancies 30% were classified as class 1, 47% were class 2 and 23% were class 3 discrepancies. The remaining 20 discrepancies were cases where deviating from the PAM would have been the right thing to do, which might suggest that an intentional but undocumented discrepancy by the prescriber writing up the admission order may have occurred. Conclusion: The results suggest that medication discrepancies in paediatric patients do occur upon hospital admission, which do have a potential to cause harm and that medicines reconciliation is a potential solution to preventing such discrepancies. References: 1. National Institute for Health and Clinical Excellence. National Patient Safety Agency. PSG001. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. London: NICE; 2007. 2. Cornish, P. L., Knowles, S. R., Marchesano, et al. Unintended Medication Discrepancies at the Time of Hospital Admission. Archives of Internal Medicine 2005; 165:424–429