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. 2023 Jul 10;8(4):e671.
doi: 10.1097/pq9.0000000000000671. eCollection 2023 Jul-Aug.

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency

Lisa M Ring  1   2   3 , Jamie Cinotti  4 , Lisa A Hom  1   2 , Mary Mullenholz  1 , Jordan Mangum  1 , Sameeya Ahmed-Winston  5 , Jenhao Jacob Cheng  1 , Ellie Randolph  4 , Ashraf S Harahsheh  1   2
Affiliations

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency

Lisa M Ring et al. Pediatr Qual Saf. .

Abstract

Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021.

Methods: This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress.

Results: Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001).

Conclusion: MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.

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Conflict of interest statement

The authors have no financial interest to declare in relation to the content of this article.

Figures

Fig. 1.
Fig. 1.
Fishbone.
Fig. 2.
Fig. 2.
Key driver diagram.
Fig. 3.
Fig. 3.
Process measure: utilization of integrated MAP.CL indicates centerline; LCL, lower control limit; UCL, upper control limit.
Fig. 4.
Fig. 4.
Second outcome measure: efficiency. CL indicates centerline; LCL, lower control limit; UCL, upper control limit.
Fig. 5.
Fig. 5.
Unmatched reasons for Cerner inpatient vs MAP inpatient.
See this image and copyright information in PMC

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References

    1. Mixon AS, Smith GR, Mallouk M, et al. . Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation. BMC Health Serv Res. 2019;19:659. - PMC - PubMed
    1. The Joint Commission. National patient safety goals effective. 2023. ed3f3bff-f7ea-4e29-87f6-74a7e0d0d852. Available at jointcommission.org.
    1. Yin HS, Neuspiel DR, Paul IM, et al. . Preventing home medication administration errors. Pediatrics. 2021;148:e2021054666. - PubMed
    1. Wilson E, Hm Chen A, Grumbach K, et al. . Effects of limited English proficiency and physician language on health care comprehension. J Gen Intern Med. 2005;20:800–806. - PMC - PubMed
    1. Trivedi SP, Corderman S, Berlinberg E, et al. . Assessment of patient education delivered at time of hospital discharge. JAMA Intern Med. 2023;183:417–423. - PMC - PubMed