O3197: Preventing Adverse Drug Events from Inadvertent Medication Orders Expiring on the Pediatric Floor

Purpose/Objectives: At NYU Long Island Children’s Services we had many Patient Safety Incidents (PSI) reports due to expired medications.
We conducted a root cause analysis showing that there was no standardized workflow to proactively discuss expiring medications.
This project sought to create a standardized workflow to review patient medications and prevent adverse drug events (ADE). By April 2024, we aim to decrease PSI reports due to inadvertent expired medications to zero by establishing a standard process to review medication orders that are due to expire on the pediatric floor.

Design/Methods: Multidisciplinary team of residents, attendings, pharmacy, quality specialists and informaticist brainstormed on creating a standard process for reviewing medications. Interventions focused on being aware of “active medications” in EMR and proactively checking for expiring medications. In October 2023, we provided resident education on patient list column of expiring medications, sidebar dashboard daily checklist, reviewing and choosing an action such as “let expire,” “renew,” etc. for expiring medications. In November 2023, we initiated a daily review of active medications during morning rounds and sign-outs from electronic medical record (not paper). In January 2023, we discussed the review of medications process at the beginning of each month. The outcome measure is the number of PSI from ADE due to inadvertent expired medications. The process measures are percentage of days per week when active and expired medications were read aloud on rounds, and number of expired medications that were caught on review per week.

Results: Since November 2023, expiring medications are reviewed at a median rate of 71% per week. We have caught as many as 6 inadvertently expiring medications in a week and intercepted in time. We have no ADE related to expiring medications since November 2023 (as of March 31, 2024 it has been 166 days since last ADE due to expiring medications).

Conclusion/Discussion: By implementing a standardized protocol for the review of expiring medication orders (through medication review at least once daily per shift as well as conducting verbal read-back of medications during rounds), we have prevented ADEs due to expiring medications. Given that medications might expire outside of the rounding window, we will review expiring medications again during evening sign outs.