Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.
Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.
OBJECTIVE: To identify and reduce medication-prescribing errors by introducing systematic physician education and post-cardiac surgery admission prescription forms. DESIGN: Errors were defined as: incomplete prescriptions; potential adverse drug events (ADEs), i.e. either intercepted or non-intercepted incorrect prescriptions not resulting in an ADE; and incorrect prescriptions that resulted in ADEs. Two baseline blinded pre-intervention data collection periods of 4 weeks and 1 week were followed by implementation of a post-cardiac surgery templated physician order and prescription form and systematic physicians\’ education. Twelve post-intervention data collections of 1-week duration were completed over a 3-year period and were either blinded or informed with reinforcement of physicians\’ education. SETTING: Tertiary paediatric cardiac intensive care unit. RESULTS: A total of 3648 prescriptions were evaluated at baseline (mean[Symbol: see text]+/-[Symbol: see text]SD of 687[Symbol: see text]+/-[Symbol: see text]8 per week) and 811[Symbol: see text]+/-[Symbol: see text]129 prescriptions during each post-intervention period. Total baseline errors of 16.8% decreased to 8.4% after the first blinded data collection and to 4.8% at the final data collection (p[Symbol: see text]<[Symbol: see text]0.001). The occurrence of incomplete prescriptions fell from 15.3% at baseline to 3.6% at final data collection (p[Symbol: see text]<[Symbol: see text]0.001); intercepted potential ADEs fell from 1.3% to 1.1%; non-intercepted potential ADEs fell from 0.17% to zero; and post-operative prescribing errors fell from 44% to 4.6% (p[Symbol: see text]<[Symbol: see text]0.001), with the major reduction seen in incomplete prescriptions. CONCLUSION: The incidence of incomplete prescriptions significantly improved with education of physicians and use of post-cardiac surgery templated physician order and prescription forms. There was no impact on potential ADEs.
Burmester MK, Dionne R, Thiagarajan RR, Laussen PC.
Department of Cardiology, Children’s Hospital, Boston, MA, USA, m.burmester@rbht.nhs.uk.