Seizure occurrence following nonoptimal anticonvulsant medication management during the transition into the hospital

Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

Optimizing anticonvulsant administration for children before anesthesia: a quality improvement project

OBJECTIVE

Children with epilepsy are at increased risk of missing scheduled anticonvulsants during the home-to-hospital transition, including when being admitted for procedures requiring anesthesia. This may contribute to breakthrough seizures because of lowered anticonvulsant levels. We conducted an interdisciplinary quality improvement project with a specific aim to increase the percentage of children receiving their anticonvulsants as scheduled before procedures requiring anesthesia.

METHODS

The Institute for Health Care Improvement methodology was used to develop an interdisciplinary team and improve the process of ensuring administration of maintenance anticonvulsants. Successful components of the improvement project included focusing on the outcome for patients, standardization of medication administration when "nothing per os" before anesthesia and development of a contingency plan when children had not received anticonvulsants at home.

RESULTS

The percentage of children receiving their anticonvulsants medications at home before procedures requiring anesthesia increased from 58 of 76 (76%) to 334 of 370 (90%) (P = 0.002). The number of children receiving maintenance anticonvulsant medications in the hospital before the procedure increased from 8 of 38 (21%) to 15 of 16 (91%) (P < 0.001).

CONCLUSION

The use of established quality improvement methods improved the number of children receiving maintenance anticonvulsants during the home-to-hospital transition. The transition into the hospital for children with chronic illnesses includes a handoff between parents and medical staff. Future efforts to improve care during the home-to-hospital transition will require sustaining these gains and the involvement of parents.