35 Assessing the completeness of medication reconciliation documentation by resident physicians at hospital admission for pediatric asthma patients

Medication errors at admission and discharge to hospital continue to be common and preventable. Medication discrepancies occur in 22–73% of hospitalized pediatric patients and are mostly related to admissions. The process of medication reconciliation (MedRec) has been identified as an important tool in reducing medication errors and is a patient safety standard in Canadian hospitals at transitions of care. Resident physicians in our tertiary pediatric hospital are responsible for completing the MedRec form at hospital admission. We hypothesized based on clinical observation that the strength of asthma inhalers is frequently omitted on the admission MedRec. Asthma is the leading cause of hospitalization in children, and incomplete information on patient’s home controller medications could impact the medical team’s ability to make an appropriate discharge plan. To describe and quantify the completeness of admission medication reconciliation documentation by resident physicians for pediatric asthma patients. This study was a single-centre, retrospective chart review of admission MedRec documentation for pediatric asthma patients from January 2016 – December 2017. Charts with an admitting diagnosis of asthma and home asthma medications on the admission MedRec were included for review. MedRec forms were deemed incomplete if asthma medications were missing drug name, strength, dose/frequency or not reconciled. Charts with an incomplete MedRec were further reviewed to determine if the reason for the incomplete medication history was documented, and if home medications were clarified prior to hospital discharge. A total of 241 charts of pediatric asthma admissions from the review period included home asthma medications on the admission MedRec. 40% of all MedRec forms reviewed had at least one medication incompletely documented. Inhaled corticosteroids were the most frequent with 40% incomplete for any reason, 37% missing the inhaler strength, 14% missing the dose/frequency, 2% not reconciled and 1% missing the drug name. Documentation of other inhalers were also more likely to be incomplete than oral asthma medications with 27% of short-acting bronchodilators and 24% of combination inhalers incomplete for any reason. No cause for the incomplete medication history was documented in 68% of charts, and 36% had no clarification order written for home asthma medications prior to hospital discharge. Documentation of inhalers on admission MedRec forms by resident physicians for pediatric asthma patients is often incomplete. Missing information on patient’s home asthma medications could result in medication errors at discharge. Future quality improvement interventions in our institution are required.

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