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Prevalence of medication discrepancies in pediatric patients transferred between hospital wards

International Journal of Clinical Pharmacy volume 43, pages 909–917 (2021)Cite this article

Abstract

Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. Setting Pediatric department of a public hospital in Northeast Brazil. Method A cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient’s caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measure Discrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.

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Funding

This work was supported in part by the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Finance Code 001.

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Affiliations

  1. Pharmaceutical Sciences Graduate Program, Laboratory of Teaching and Research in Social Pharmacy (LEPFS-UFS), Federal University of Sergipe, São Cristóvão, Brazil

    Thaciana dos Santos Alcântara, Fernando Castro de Araújo Neto, Helena Ferreira Lima & Divaldo P. de Lyra Junior

  2. Health Sciences Graduate Program, Laboratory of Teaching and Research in Social Pharmacy (LEPFS-UFS), Federal University of Sergipe, São Cristóvão, Brazil

    Dyego Carlos S. Anacleto de Araújo, Giulyane Targino Aires-Moreno & Divaldo P. de Lyra Junior

  3. Laboratory of Teaching and Research in Social Pharmacy (LEPFS-UFS), Federal University of Sergipe, São Cristóvão, Brazil

    Júlia Mirão Sanchez

  4. Department of Pharmacy, Life Sciences Institute, Federal University of Juiz de Fora, Campus Governador Valadares, Governador Valadares, Brazil

    Carina de Carvalho Silvestre

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  1. Thaciana dos Santos Alcântara
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  2. Fernando Castro de Araújo Neto
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Correspondence to Divaldo P. de Lyra Junior.

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Alcântara, T.d., de Araújo Neto, F.C., Lima, H.F. et al. Prevalence of medication discrepancies in pediatric patients transferred between hospital wards. Int J Clin Pharm 43, 909–917 (2021). https://doi.org/10.1007/s11096-020-01196-w

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  • DOI: https://doi.org/10.1007/s11096-020-01196-w

Keywords

  • Children
  • Hospitals
  • Medication discrepancies
  • Medication errors
  • Patient transfer