• Article
  • August 30, 2018

Revamping the Discharge Process to Reduce Medication Errors

When Children's Hospital at Montefiore discovered parents didn't fully understand the medications providers sent their children home with, staff developed a new framework called MEDRITES for teaching about medications.

By Kelly Church

It takes more than a decade to become a doctor in the U.S. By the time medical students complete pre-med, medical school and a residency program, they've received exhaustive training—roughly 12,480 hours during a three-year residency program. However, few medical schools formally teach students how to discharge a patient, a crucial step that helps transition patients from hospital to home.

"There's no class called, 'How Do You Discharge a Patient?'" says Michael Rinke, M.D., Ph.D., and medical director of Pediatric Quality at Children's Hospital at Montefiore (CHAM) in Bronx, New York. "Yet, that is some of the most important information at the most critical times we have with our patients."

Eyeing discrepancies

When CHAM began using a new electronic medical record (EMR) system, the process for discharging a patient changed, causing a lack of clarity around who was responsible for explaining medications to families. The system change highlighted a problem: a patient's discharge summary didn't always match the medication list sent home with parents.

"This was reflected in a caregiver's lack of understanding about medications we were sending children home with," says Kaitlyn Philips, D.O., M.S., and assistant medical director of Pediatric Quality at CHAM.

Philips was the first to notice discrepancies in discharge medication lists. She spent three months calling parents and caregivers after discharge asking a series of questions to gauge the caregiver's understanding of the medication the child was sent home with. An incorrect answer on any question was counted as a discharge-related medication error. Philips called more than 250 caregivers, with about half showing a lack of understanding of medication side effects, not knowing what symptoms to look for in their child.

Revamping the discharge process

Philips developed MEDRITES, an acronym that provides the new framework for discharging children with medication lists. A team of nurses, residents, pharmacists, hospital leaders and a quality improvement specialist created MEDRITES. It improves "not only who thought about medications, but also how we thought about medication," Philips says. All team members use MEDRITES when discharging a patient, whether from the pharmacy or inpatient unit.

"The project emphasized it shouldn't just be one of those people addressing medications with the family," says Rinke. "All of those people should be teaching on medications. It really is a multidisciplinary team effort to get this done. We tried to spread the responsibility of medication education."

Each letter of MEDRITES represents a point of conversation the physician, pharmacist, nurse or other staff member covers with the patient and his or her family:

  • Medication name 
  • Engagement of family: what the family already knows about the medication
  • Dose: the recommended dose 
  • Route: how the child takes the medication, whether internally or topically  
  • Indication: why the child is taking the medication and how the caregiver can know if it's working
  • Timing: when the child should take the medication, starting with the next dose after discharge, how many times per day and when during the day
  • Effects: common side effects
  • Storage/supply a syringe: how the medication should be stored, and providers are encouraged to demonstrate drawing an appropriate dose  '

Philips says the discussion with the family typically starts with the medication name, and inviting the family to share what they already know. Hospital staff fills in the blanks using MEDRITES as a guide to ensure the family has all the information.

To help improve documentation, smartphrases that document the same elements in MEDRITES were incorporated into the EMR for the most common medications that children were being sent home on, including oral steroids, allergy medications and antibiotics.

Introducing the new process to staff 

Rolling out the new discharge practice was an all-hands-on-deck scenario. Philips' team members across all areas of the hospital advocated for the new process so the team could introduce the comprehensive approach at one time.

"It was a slow process in the beginning in terms of getting people to realize it was a problem," says Philips. "The biggest challenge was obtaining buy-in from the frontline staff to adjust the way they educate about medications."

Philips' team gave staff access to the EMR smartphrases at the same time teams held interdepartmental meetings to align how staff across the hospital trained patients and families on medications. The outpatient community pharmacy that offers prescription delivery was also included to ensure consistent medication training outside of the hospital.

Interns were given what Philips calls "deliberate practice." These one-on-one exercises were mock medication trainings where the intern would teach Philips, a resident or attending about discharge medications and receive real-time feedback.

Seeing results

As the project continued and staff used MEDRITES and the EMR smartphrases, Philips shared status updates to keep stakeholders and frontline staff informed on progress. On a monthly basis, she'd share email updates with data to demonstrate how everyone's hard work was paying off. However, between those monthly emails, Philips would share additional information any time there was a success story.

"If there was a family that said, "My nurse did such a wonderful job teaching me. I feel so much more comfortable knowing this,' or, "The pharmacist did an excellent job,' I would send an email to the staff member and their supervisors," Philips says. "The more that people realized we're actually making a difference, the more it caught on."

This real time feedback, both positive and negative, Philips says, helped change the culture of medication education. At the start of the pre-intervention phase in April 2017, the team was averaging a 71 percent discharge medication-related failure rate. At the end of their intervention phase a year later, the team was seeing a 37 percent failure rate, which is a 34 percent decrease in discharge medication-related errors. 

Next steps

Philips is expanding her work to include other parts of the discharge process, not just medication documentation. She wants to focus on ensuring parents know about follow-up appointments and their importance, when their child can return to school and what to watch for when their child is home. "We're also incorporating some Spanish smartphrases to make our documentation appropriate for a wider population of our patients," Philips says.

After that, Philips hopes to expand to other areas of the hospital. She's working with the adolescent medicine teams and hematology/oncology teams to find other areas of improvement.

For other hospitals looking to introduce similar quality improvement efforts, Philips says the project requires more staff buy-in than anything else.

"Implementation of this project is feasible with a limited budget and resources," Philips says. "It's imperative to involve all possible providers who have a role in the discharge medication process, from pharmacy staff, to nursing and attending physicians. By encouraging new staff to adopt these methods early in their training, we shaped the way they perform discharge talks throughout their entire residency and, hopefully, career." 

Send questions or comments to magazine@childrenshospitals.org.