576 - Sustaining Safe Essential Medication Reconciliation and Ordering Processes in a Pediatric ED Across an EHR Transition

Publication Number: 1553.576

Jessica K. Creedon, Boston Children's Hospital, Dover, MA, United States; Niloufar Paydar-Darian, Boston Children's Hospital, Boston, MA, United States; Andrew J. Capraro, Boston Childrens Hospital, Boston, MA, United States; Kathleen Kiley, Boston Children's Hospital, Boston, MA, United States; Melissa Sundberg, Boston Children's Hospital, Boston, MA, United States; John J. Porter, Boston Children's Hospital, Boston, MA, United States; Caitlin Kent, Boston Children's Hospital, Norfolk, MA, United States; Megan Trexler, Boston Children's Hospital, Walpole, MA, United States; Joel Hudgins, The Warren Alpert Medical School of Brown University, Providence, RI, United States

Background: Implementing a new electronic health record (EHR) commonly precipitates a spike in medication safety events. Our high-volume pediatric emergency department (ED) previously demonstrated a baseline improvement in the timely ordering of essential home medications (anti-epileptics, immunosuppressants, cardiac agents) without compromising internal safety metrics. Sustaining these gains during and after an EHR transition poses significant risk and operational challenge.

Objective: To evaluate whether improvements in timely and accurate essential home medication reconciliation and ordering were sustained without an increase in high-level medication safety events during and after an institutional EHR transition.

Design/Methods: Using Statistical Process Control (SPC), we monitored three categories of measures monthly. The primary outcome was the rate of high-level internal safety events involving the omission, delay, or incorrect dosing of essential home medications. Our process measures included the rate of essential medications ordered within four hours of triage (for ED encounters lasting >4 hours) and the completion rate of medication histories. We used medications ordered per encounter as our balancing measure. To support the sustainment of the new workflow, we reinforced changes through an online interactive training module for nurses and prescribers, complemented by in-person one-on-one training, on-site champions, and readily available in-system references.

Results: The ED did not experience an increase in high-level home medication safety events following the EHR transition. Since the initiative began in 2022, the interval between safety events lengthened, reflecting improved reliability. Additionally, there have been no documented internal events related to home medication safety in the ED since the EHR transition. Compliance with the new training modules reached 89% for nursing medication reconciliation and 76% for prescriber medication ordering. Furthermore, the home medication history completion rate for admitted patients improved markedly from a baseline of 60% to 90%. No significant difference was observed in the rate of essential medication ordering when comparing pre- and post-EHR periods.

Conclusion(s): The safe continuation of essential home medication ordering was sustained through an EHR transition, without an increase in high-level safety events, via a combined strategy of targeted education and EHR-embedded workflows. These results offer a reproducible model that other EDs can adopt to maintain medication safety through major EHR workflow transitions.

ED Medication History Completion Rate for Patients Admitted from the ED
ED Medication History Completion Rate for Patients Admitted from the ED over 2-year period inclusive of EHR transition

ED Internal Safety Events related to Home Medication (Omission, Delay, Incorrect Dosing)
G-chart demonstrating decreased frequency and increased interval between ED internal events related to Home/Outpatient Medication safety. Count of number of events where ED patients with an ESI score 1-3 who received a medication without a related event. Notably, the last high severity internal event was prior to EHR transition with 50,000 events of medications ordered since that event (with no subsequent additional event noted on the x-axis).