Anticonvulsant Medication Errors in Children With Epilepsy During the Home-to-Hospital Transition

Abstract

Children with epilepsy are at risk of having their anticonvulsant regimens disrupted during the home-to-hospital transition. We sought to estimate the frequency of anticonvulsant medication errors during transition into the hospital in children with epilepsy hospitalized for reasons other than seizures, and to examine factors associated with the occurrence of such errors. We examined the medical records to identify errors related to anticonvulsant administration during the transition into the hospital and we examined potential risk factors for error occurrence. Errors were classified as relating to dosing quantity or missing a dose. Among 120 children, 29 (24%) experienced an anticonvulsant medication error. In a multivariable model, the risk factors of changes in responsibility for anticonvulsant administration and frequency of anticonvulsant administration were strongly associated with increased odds of errors. Anticonvulsant medication errors during the home-to-hospital transition may be unacceptably common in children with epilepsy hospitalized for reasons other than seizures.

Keywords

patient safety medication errors epilepsy transitions

Get full access to this article

View all access options for this article.

References

Kohn

Corrigan

Donaldson

, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.

Brennan

Leape

Laird

. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324:370–376.

Larsen

Parker

. Patients' safety: think and act locally. Lancet. 2008;371:364–365.

Bates

Cullen

Laird

. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA. 1995;274:29–34.

Kaushal

Bates

Landrigan

. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114–2120.

Miller

Elixhauser

Zhan

. Patient safety events during pediatric hospitalizations. Pediatrics. 2003;111(6 pt 1):1358–1366.

Greenwald

Halasyamani

Greene

. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5:477–485.

Dosa

Boeing

Kanter

. Excess risk of severe acute illness in children with chronic health conditions. Pediatrics. 2001;107:499–504.

Graham

Dumas

O'Brien

Burns

. Congenital neurodevelopmental diagnoses and an intensive care unit: defining a population. Pediatr Crit Care Med. 2004;5:321–328.

10.

Mestrovic

Kardum

Polic

. The influence of chronic health conditions on susceptibility to severe acute illness of children treated in PICU. Eur J Pediatr. 2006;165:526–529.

11.

Simon

Berry

Feudtner

. Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126:647–655.

12.

Slonim

LaFleur

Ahmed

Joseph

. Hospital-reported medical errors in children. Pediatrics. 2003;111:617–621.

13.

Kilbridge

Noirot

Reichley

. Computerized surveillance for adverse drug events in a pediatric hospital. J Am Med Inform Assoc. 2009;16:607–612.

14.

Hughes

Clancy

. Improving the complex nature of care transitions. J Nurs Care Qual. 2007;22:289–292.

15.

Clancy

. Care transitions: a threat and an opportunity for patient safety. Am J Med Qual. 2006;21:415–417.

16.

Bell

Brener

Gunraj

. Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases. JAMA. 2011;306:840–847.

17.

World Alliance for Patient Safety Forward Programme; Who Draft Guideline for Adverse event reporting and learning systems. Geneva: World Heath Organization; 2005. http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf. Accessed March 30, 2012.

18.

Cramer

Glassman

Rienzi

. The relationship between poor medication compliance and seizures. Epilepsy Behav. 2002;3:338–342.

19.

Dutta

Reed

. Effect of delayed and/or missed enteric-coated divalproex doses on valproic acid concentrations: simulation and dose replacement recommendations for the clinician. J Clin Pharm Ther. 2006;31:321–329.

20.

Ahmad

Garnett

. Carbamazepine extended-release capsules vs. oxcarbazepine: computer simulations of the effect of missed doses on drug plasma concentrations. Curr Med Res Opin. 2005;21:1363–1368.

21.

National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Taxonomy of Medication Errors. http://www.nccmerp.org/pdf/taxo2001-07-31.pdf. Accessed March 30, 2012.

22.

Modi

Rausch

Glauser

. Patterns of nonadherence to antiepileptic drug therapy in children with newly diagnosed epilepsy. JAMA. 2011;305:1669–1676.

23.

Holdsworth

Fichtl

Behta

. Incidence and impact of adverse drug events in pediatric inpatients. Arch Pediatr Adolesc Med. 2003;157:60–65.

24.

Stone

Boehme

Mundorff

Maloney

Srivastava

. Hospital admission medication reconciliation in medically complex children: an observational study. Arch Dis Child. 2010;95:250–255.

25.

Gonzales

. Medication administration errors and the pediatric population: a systematic search of the literature. J Pediatr Nurs. 2010;25:555–565.