142 - Evaluation of Factors Associated with Medication Errors in Antimicrobial Stewardship Program Medications

Poster Number: 142
Publication Number: 142.416

Katherine M. Tang, The Children's Hospital at Montefiore, New York, NY, United States; Grace Murphy, Albert Einstein College of Medicine, Bronx, NY, United States; Philip Lee, The Children's Hospital at Montefiore, Bronx, NY, United States; Brenda I. Anosike, Albert Einstein College of Medicine/Montefiore Medical Center - - New York, NY, Bronx, NY, United States; Kaitlyn Philips, The Children's Hospital at Montefiore, Bronx, NY, United States

Background: Antimicrobial Stewardship Programs (ASP) were developed to improve appropriate and judicial prescribing of antimicrobial medications in hospitals. However, obtaining ASP approval of these restricted antimicrobials alters the standard process for prescribing medications, increasing the opportunity for error. The specific characteristics of these medication errors is not well studied.

Objective: Describe the frequency of and factors associated with medication errors for ASP medication orders on the inpatient units at a large, metropolitan tertiary care children’s hospital.

Design/Methods: This retrospective cohort study occurred from 1/2020 to 12/2020. Inclusion criteria were children (≤21 years) admitted to inpatient or intensive care units and prescribed an ASP medication. Exclusion criteria were orders for a single dose and orders placed for doses administered from 11PM to 8AM when the ASP team is off. An ASP medication was a restricted antimicrobial requiring ASP approval (e.g. vancomycin, meropenem, acyclovir). A randomly selected convenience sample of approximately 75 charts per month was reviewed. The primary outcome was proportion of orders with a medication error. An error was defined as incorrect prescription, pharmacy preparation, and/or medication administration, which included incorrect timing of any dose in the first 72 hours of order placement. We analyzed the association of a medication error with patient demographics (age, sex, race/ethnicity), order characteristics (frequency, route, time of order placement), and presence of an infectious disease consult using chi square tests and Mann-Whitney U tests as appropriate.

Results: A total of 902 orders of ASP medications were evaluated. An error was associated with 499 (55%) orders. Increased medication frequency was significantly associated with a higher likelihood of error. Medications given 3 (48.7% of errors) or 4 (29.5%) times per day were more likely to have errors than those given twice a day (16.2%) or daily/every other day (5.6%) (p=0.001) (Table 1). Medication orders with and without an error did not significantly differ on patient demographics, medication route, the day or shift the order was placed, and presence of an infectious disease consult.Conclusion(s): Errors associated with ASP medications are frequent, with 55% of orders experiencing any type of error in the first 72 hours. Medications ordered for a greater frequency are more prone to errors. Therefore, efforts to reduce the proportion of errors associated with ASP medications is necessary.
Katherine Tang CV.pdf