• Prescribing errors
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Improving paediatric prescribing

An ongoing project to improve paediatric prescribing, involving all doctors prescribing for children in our hospital.

The problem

A high incidence of errors and omissions identified in audit of prescription charts, despite paediatric prescribing being discussed at every junior doctor induction programme, led to initiation of this project.

The problem had already been quantified by previous audits. Doing a weekly prescribing review by randomly selecting two drug charts from each of the three wards and discussing them as a team helped identify key issues. This led to all staff being actively involved from the early stages. Various interventions were introduced as follows.

Aims

We aimed to address all the common prescribing errors/omissions identified during the first cycles of the project and maintain the improvement while trainees rotated from other posts.

The goal was 100% BNFC general guidance compliant drug charts by the end of January 2015 for all medical paediatric patients.

(For information on the BNFC guidance, see https://www.evidence.nhs.uk/formulary/bnfc/current/general-guidance/prescription-writing)

Making the case for change

This project is designed as per the Plan-Do-Study-Act Cycle suggested by the Institute for Healthcare Improvement’s Model for Improvement: small sample cycles were performed to identify the main prescribing problems, implement changes and test the effect of each intervention.

The goal was 100% BNFC general guidance compliant drug charts by the end of January 2015 for all medical paediatric patients.

At the final stage of the project (February 2015) measures aiming to preserve the improvement overtime will be introduced and will be tested after the trainees rotate (March 2015).

Interventions were escalated to achieve the desired outcome, with weekly performance monitoring by review of randomly selected drug charts and later by review of up to all the drug charts in the Paediatric Wards monthly.

Cycle 1: Review of drug charts to Identify problems

Cycle 2: ‘’Prescribing lesson of the week’’ posters in the doctors’ office

Cycle 3: Personal emails with recommendations to individuals who had made errors/omissions

Cycle 4: Combining personal emails with a themed, eye-catching poster

Cycle 5: Introducing star chart to positively motivate good performance, continuing personal emails

Cycle 6 & 7: Increasing sample size- all charts from one ward/all paediatric wards

Cycle 8 (March 2015): Re-audit

Your improvement

Fewer prescription errors and omissions were noted following the implementation of interventions with inferred improvement in patient care.

We managed to improve and maintain the average prescribing performance and this was demonstrated both by numbers and by staff feedback.

The project is not completed and we have not achieved the 100% target yet but we have achieved and sustained high performance on prescribing parts where we scored very low before the initiation of the project (e.g. prescribing oxygen, writing the indication/intended review date or duration for antibiotics).

Learning and next steps

Sustained team focus and escalating interventions tested in rapid cycles led to the desired outcome becoming achievable.

 All staff were active participants at every stage and consequently were aware of planned interventions. Staff involvement early in the choice of intervention may have shortened the time to achievement of goal and reduced resistance. Positive identification of individual good practice motivates improvement.

Quality assurance/MHRA Registration

The project has been approved by the Paediatric Department. It is planned to be presented it at the audit meeting of the local Trust on 21st of May, 2015.