Medication reconciliation and polypharmacy in children — branching viva · Paeds Vivas

Prompt

You are the paediatric registrar responsible for medication safety across ED, ward and discharge. The examiner will challenge definitions, prioritisation and counselling.

Stem

The examiner will move from definitions to a complex discharge and then to deprescribing. [1] [6]

Branch 1 — Definitions

Examiner: What is medication reconciliation? [1]

Strong answer: A verified process: gather sources, build BPMH, compare at transitions, resolve intentional versus unintentional differences, communicate the final plan. Not a checkbox. [1] [23]

Examiner: What is a BPMH? [1]

Strong answer: Best Possible Medication History from multiple sources including caregiver and bottles, with dose, form/concentration, route, frequency, indication and last dose. [1] [18]

Branch 2 — Prioritisation

Examiner: Admission list omits a home anticonvulsant present in the bag. [13]

Strong answer: Treat as clinically important unintentional omission until proven otherwise. Clarify same shift; do not prescribe from the screen alone; restore appropriate therapy while managing seizures. [13] [17] [1]

Branch 3 — CMC polypharmacy

Examiner: A child with medical complexity is on many medicines. Is that automatically malpractice? [6]

Strong answer: No. Multiple medicines are common in CMC. The task is safer polypharmacy: indication, monitoring, interaction check, burden reduction and coordinated prescribing. [6] [7] [27]

Branch 4 — Liquid dosing

Examiner: How do you discharge a toddler on a new antibiotic liquid? [34]

Strong answer: State concentration and volume; supply oral syringe; avoid kitchen spoons; teach-back demonstration; written plan; interpreter if needed. [34] [35] [36]

Branch 5 — System and handoff

Examiner: Night team says meds unchanged after a major anticonvulsant switch. [11]

Strong answer: Explicitly communicate medication changes in structured handoff. Reconciliation and handoff are complementary safety behaviours. [11] [1]

Examiner extras

Adult discrepancy literature informs mechanism; do not recite adult percentages as paediatric constants. [21] [22]
QI may improve completion; accuracy still needs verification. [2] [5]
Deprescribe with a plan; do not abrupt-stop medicines that need taper without reasoning. [14]

References

[1]Merandi, Jenna Medication Reconciliation. Pediatrics in review, 2017.PMID 28044039
[2]Sheth, Sarika Standardizing Medication Reconciliation in a Pediatric Emergency Department. Pediatrics, 2024.PMID 38273780
[3]Condren, Michelle Medication Reconciliation Across Care Transitions in the Pediatric Medical Home. Joint Commission journal on quality and patient safety, 2019.PMID 30898508
[4]Morse, Keith E Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals. Pediatric quality & safety, 2021.PMID 34345749
[5]Gunkelman, Samantha M Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project. Hospital pediatrics, 2024.PMID 38529561
[6]Feinstein, James A Making Polypharmacy Safer for Children with Medical Complexity. The Journal of pediatrics, 2023.PMID 36252865
[7]Huth, Kathleen Medication safety for children with medical complexity. Paediatrics & child health, 2020.PMID 33178368
[8]Zanin, Anna Polypharmacy in Children with Medical Complexity: A Cross-Sectional Study in a Pediatric Palliative Care Center. Children (Basel, Switzerland), 2024.PMID 39062270
[9]Alqenae, Fatema A Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug safety, 2020.PMID 32125666
[10]Aires-Moreno, Giulyane Targino Medication discrepancies in transition of care of hospitalised children in Brazil: a multicentric study. Archives of disease in childhood, 2021.PMID 33958348
[11]Starmer, Amy J Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
[12]Gattari, Theresa B Medication Discrepancies at Pediatric Hospital Discharge. Hospital pediatrics, 2015.PMID 26231634
[13]Louiselle, Katie Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2021.PMID 34035684
[14]Moss, James G Paediatric polypharmacy and deprescribing: the views of UK healthcare professionals. Archives of disease in childhood, 2023.PMID 35701176
[15]Zito, Julie M Psychotropic Polypharmacy in the US Pediatric Population: A Methodologic Critique and Commentary. Frontiers in psychiatry, 2021.PMID 34194346
[16]DeCourcey, Danielle D Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2017.PMID 28198758
[17]Huynh, Chi An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital. Archives of disease in childhood, 2016.PMID 26566687
[18]Huynh, Chi Medication discrepancies at transitions in pediatrics: a review of the literature. Paediatric drugs, 2013.PMID 23670796
[19]Huynh, Chi An evaluation of paediatric medicines reconciliation at hospital discharge into the community. The International journal of pharmacy practice, 2016.PMID 26670624
[20]Wong, Jacqueline D Medication reconciliation at hospital discharge: evaluating discrepancies. The Annals of pharmacotherapy, 2008.PMID 18780806
[21]Cornish, Patricia L Unintended medication discrepancies at the time of hospital admission. Archives of internal medicine, 2005.PMID 15738372
[22]Tam, Vincent C Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2005.PMID 16129874
[23]Kwan, Janice L Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of internal medicine, 2013.PMID 23460096
[24]Mueller, Stephanie K Hospital-based medication reconciliation practices: a systematic review. Archives of internal medicine, 2012.PMID 22733210
[25]Coffey, Maitreya Prevalence and clinical significance of medication discrepancies at pediatric hospital admission. Academic pediatrics, 2009.PMID 19640822
[26]Kulawiak, Jessica Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children's Hospital. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2024.PMID 39411418
[27]Grossberg, Richard Polypharmacy-An Important Contributor to Health and Safety for Children With Medical Complexity: How Can We Improve Care for This Vulnerable Population? The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2024.PMID 38596412
[28]Reedy, Julia Challenges of managing pediatric polypharmacy in a pediatric complex care program: A qualitative pilot study. Journal of the American Pharmacists Association : JAPhA, 2025.PMID 40127839
[29]Alcântara, Thaciana Dos Santos Prevalence of medication discrepancies in pediatric patients transferred between hospital wards. International journal of clinical pharmacy, 2021.PMID 33175294
[30]Kuo, Dennis Z Recognition and Management of Medical Complexity. Pediatrics, 2016.PMID 27940731
[31]Kuo, Dennis Z Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[32]Zennaro, Margherita Improving Medication Safety Through Medication Reconciliation in Pediatric Neurology: Clinical Pharmacist Recommendations and Physician Uptake in a 13-Week Study. Children (Basel, Switzerland), 2025.PMID 40426804
[33]Adducchio, Sara Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit. Neurology. Clinical practice, 2024.PMID 38524835
[34]Yin, H Shonna Preventing Home Medication Administration Errors. Pediatrics, 2021.PMID 34851406
[35]Yin, H Shonna Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics, 2017.PMID 28759396
[36]Yin, H Shonna Effect of Medication Label Units of Measure on Parent Choice of Dosing Tool: A Randomized Experiment. Academic pediatrics, 2016.PMID 27155289

Branch 1 — Definitions

Examiner: What is medication reconciliation? [1]

Strong answer: A verified process: gather sources, build BPMH, compare at transitions, resolve intentional versus unintentional differences, communicate the final plan. Not a checkbox. [1] [23]

Examiner: What is a BPMH? [1]

Strong answer: Best Possible Medication History from multiple sources including caregiver and bottles, with dose, form/concentration, route, frequency, indication and last dose. [1] [18]

Examiner extras

Adult discrepancy literature informs mechanism; do not recite adult percentages as paediatric constants. [21] [22]

QI may improve completion; accuracy still needs verification. [2] [5]

Deprescribe with a plan; do not abrupt-stop medicines that need taper without reasoning. [14]

References

[1]Merandi, Jenna Medication Reconciliation. Pediatrics in review, 2017.PMID 28044039
[2]Sheth, Sarika Standardizing Medication Reconciliation in a Pediatric Emergency Department. Pediatrics, 2024.PMID 38273780
[3]Condren, Michelle Medication Reconciliation Across Care Transitions in the Pediatric Medical Home. Joint Commission journal on quality and patient safety, 2019.PMID 30898508
[4]Morse, Keith E Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals. Pediatric quality & safety, 2021.PMID 34345749
[5]Gunkelman, Samantha M Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project. Hospital pediatrics, 2024.PMID 38529561
[6]Feinstein, James A Making Polypharmacy Safer for Children with Medical Complexity. The Journal of pediatrics, 2023.PMID 36252865
[7]Huth, Kathleen Medication safety for children with medical complexity. Paediatrics & child health, 2020.PMID 33178368
[8]Zanin, Anna Polypharmacy in Children with Medical Complexity: A Cross-Sectional Study in a Pediatric Palliative Care Center. Children (Basel, Switzerland), 2024.PMID 39062270
[9]Alqenae, Fatema A Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review. Drug safety, 2020.PMID 32125666
[10]Aires-Moreno, Giulyane Targino Medication discrepancies in transition of care of hospitalised children in Brazil: a multicentric study. Archives of disease in childhood, 2021.PMID 33958348
[11]Starmer, Amy J Changes in medical errors after implementation of a handoff program. The New England journal of medicine, 2014.PMID 25372088
[12]Gattari, Theresa B Medication Discrepancies at Pediatric Hospital Discharge. Hospital pediatrics, 2015.PMID 26231634
[13]Louiselle, Katie Medication Discrepancy Risk Factors for Pediatric Patients With Epilepsy at Hospital Admission. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2021.PMID 34035684
[14]Moss, James G Paediatric polypharmacy and deprescribing: the views of UK healthcare professionals. Archives of disease in childhood, 2023.PMID 35701176
[15]Zito, Julie M Psychotropic Polypharmacy in the US Pediatric Population: A Methodologic Critique and Commentary. Frontiers in psychiatry, 2021.PMID 34194346
[16]DeCourcey, Danielle D Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies, 2017.PMID 28198758
[17]Huynh, Chi An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital. Archives of disease in childhood, 2016.PMID 26566687
[18]Huynh, Chi Medication discrepancies at transitions in pediatrics: a review of the literature. Paediatric drugs, 2013.PMID 23670796
[19]Huynh, Chi An evaluation of paediatric medicines reconciliation at hospital discharge into the community. The International journal of pharmacy practice, 2016.PMID 26670624
[20]Wong, Jacqueline D Medication reconciliation at hospital discharge: evaluating discrepancies. The Annals of pharmacotherapy, 2008.PMID 18780806
[21]Cornish, Patricia L Unintended medication discrepancies at the time of hospital admission. Archives of internal medicine, 2005.PMID 15738372
[22]Tam, Vincent C Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 2005.PMID 16129874
[23]Kwan, Janice L Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Annals of internal medicine, 2013.PMID 23460096
[24]Mueller, Stephanie K Hospital-based medication reconciliation practices: a systematic review. Archives of internal medicine, 2012.PMID 22733210
[25]Coffey, Maitreya Prevalence and clinical significance of medication discrepancies at pediatric hospital admission. Academic pediatrics, 2009.PMID 19640822
[26]Kulawiak, Jessica Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children's Hospital. The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2024.PMID 39411418
[27]Grossberg, Richard Polypharmacy-An Important Contributor to Health and Safety for Children With Medical Complexity: How Can We Improve Care for This Vulnerable Population? The journal of pediatric pharmacology and therapeutics : JPPT : the official journal of PPAG, 2024.PMID 38596412
[28]Reedy, Julia Challenges of managing pediatric polypharmacy in a pediatric complex care program: A qualitative pilot study. Journal of the American Pharmacists Association : JAPhA, 2025.PMID 40127839
[29]Alcântara, Thaciana Dos Santos Prevalence of medication discrepancies in pediatric patients transferred between hospital wards. International journal of clinical pharmacy, 2021.PMID 33175294
[30]Kuo, Dennis Z Recognition and Management of Medical Complexity. Pediatrics, 2016.PMID 27940731
[31]Kuo, Dennis Z Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics, 2018.PMID 29496973
[32]Zennaro, Margherita Improving Medication Safety Through Medication Reconciliation in Pediatric Neurology: Clinical Pharmacist Recommendations and Physician Uptake in a 13-Week Study. Children (Basel, Switzerland), 2025.PMID 40426804
[33]Adducchio, Sara Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit. Neurology. Clinical practice, 2024.PMID 38524835
[34]Yin, H Shonna Preventing Home Medication Administration Errors. Pediatrics, 2021.PMID 34851406
[35]Yin, H Shonna Pictograms, Units and Dosing Tools, and Parent Medication Errors: A Randomized Study. Pediatrics, 2017.PMID 28759396
[36]Yin, H Shonna Effect of Medication Label Units of Measure on Parent Choice of Dosing Tool: A Randomized Experiment. Academic pediatrics, 2016.PMID 27155289