Medication Order Errors at Hospital Admission Among Children With Medical Complexity

Kevin Blaine, John Wright, Amy Pinkham, Margaret O'Neill, Sarah Wilkerson, Jayne Rogers, Sarah McBride, Charis Crofton, Sarah Grodsky, David Hall, Sangeeta Mauskar, Vinita Akula, Alisa Khan, Alexandra Mercer, Jay G. Berry

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Objectives: We sought to characterize the nature and prevalence of medication order errors (MOEs) occurring at hospital admission for children with medical complexity (CMC), as well as identify the demographic and clinical risk factors for CMC experiencing MOEs. Methods: Prospective cohort study of 1233 hospitalizations for CMC from November 1, 2015, to October 31, 2016, at 2 children's hospitals. Medication order errors at admission were identified prospectively by nurse practitioners and a pharmacist through direct patient care. The primary outcome was presence of at least one MOE at hospital admission. Statistical methods used included χ2 test, Fisher exact tests, and generalized linear mixed models. Results: Overall, 6.1% (n = 75) of hospitalizations had ≥1 MOE occurring at admission, representing 112 total identified MOEs. The most common MOEs were incorrect dose (41.1%) and omitted medication (34.8%). Baclofen and clobazam were the medications most commonly associated with MOEs. In bivariable analyses, MOEs at admission varied significantly by age, assistance with medical technology, and numbers of complex chronic conditions and medications (P < 0.05). In multivariable analysis, patients receiving baclofen had the highest adjusted odds of MOEs at admission (odds ratio, 2.2 [95% confidence interval, 1.2-3.8]). Conclusions: Results from this study suggest that MOEs are common for CMC at hospital admission. Children receiving baclofen are at significant risk of experiencing MOEs, even when orders for baclofen are correct. Several limitations of this study suggest possible undercounting of MOEs during the study period. Further investigation of medication reconciliation processes for CMC receiving multiple chronic, home medications is needed to develop effective strategies for reducing MOEs in this vulnerable population.

Original languageEnglish (US)
Pages (from-to)E156-E162
JournalJournal of patient safety
Issue number1
StatePublished - Jan 1 2022
Externally publishedYes


  • Adverse medical event
  • Baclofen
  • Home/chronic medication
  • Medication reconciliation
  • Polypharmacy

ASJC Scopus subject areas

  • Leadership and Management
  • Public Health, Environmental and Occupational Health


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