P40 Impact of an educational intervention program on handwritten prescription errors in a paediatric critical care unit
Authors: Emily Siu 
Published: January 2018

Introduction

Medication errors are a major source of concern in the paediatric intensive care unit (PCCU).1 To further improve medication safety on PCCU, we aim to reduce handwritten prescription errors by implementing an educational intervention program and auditing its impact.

Aim

To audit handwritten prescription errors on the paediatric critical care unit before and after an educational error reduction intervention.

Method

Handwritten prescriptions were audited by the ward pharmacist for 2 months prior to the intervention. Errors were defined as incorrect dose for age, weight, indication, incorrect route, missing information, wrong prescription chart, inappropriate prescription. These errors were also categorised by prescriber, medication and nature of the error. Prescribers were alerted to errors at time of identification and explained how to correctly prescribe this in future. After 2 months, an educational intervention program was implemented on the same group of prescribers. This consisted of individual reminders for prescribers who made the error during the pre-intervention audit period and a summary of the most important errors emailed to all PCCU registrars. The audit continued after the intervention for another 2 weeks and collected information on errors as well as prescriptions written correctly for previously incorrectly prescribed medications.

Result

Of the 11 prescription errors found in the pre- intervention audit, 9 were by PCCU prescribers. 5 of these errors were selected for dissemination to all prescribers via email based on severity and appropriateness. One of these were prescribed correctly after the intervention by the original prescriber who made the error. The other 4 prescription issues in the email were not encountered during the 2 week audit post intervention. 2 prescription errors were made in the post interventional audit, all by PCCU prescribers. One of these errors were targeted in the educational intervention, and made by a prescriber who did not make the original error in the pre-intervention audit.

Conclusion and discussions

The educational intervention implemented has shown to prevent the prescriber from making the same mistake on one occasion. However, it did not show that it could prevent all other prescribers from making the same error. This could be due to the error being made 1 day after the email summary was sent and the prescribers might not have all read it at the time.

Limitations of this audit include the different length of pre and post intervention audit which made comparison of errors numbers difficult. The pre-intervention audit was extended due to small numbers of prescription errors made, which could be related to fewer prescriptions written during the quieter summer season. This resulted in a shortened post intervention audit period. Greater prescriber experience could also have an effect on errors and future audits with other groups of prescribers with no educational intervention may help account for this influence.

The implementation of this education intervention has shown mixed effects on reducing handwritten prescription errors on PCCU. We aim to replicate this intervention and audit for a longer period during the winter season to further examine its effects.

Reference

Potts AL, Barr FE, Gregory DF, Wright L, Patel NR. Computerised physician order entry and medication errors in a paediatric critical care unit. Pediat2004;113(1):59–63.