Improving paediatric prescribing in a low resource setting
Project undertaken on the paediatric ward of a Kenyan district general hospital, with patients aged 0-12 years.
Prescribing on the paediatric ward was very poor, with multiple errors. The morbidity and potential risk of mortality associated with drug errors is widely recognised. There was a lack of awareness among the medical staff regarding this, and the potential for harm.
Despite regular informal teaching on the ward round and discussion regarding the potential harm caused by medication and prescribing errors, there was little improvement in prescribing habits.
Nearly all prescribing was done by the most junior staff, clinical and medical officer interns, with minimal safety netting.
The aim of this project was to improve the quality of prescribing on the paediatric ward; to deliver teaching to the junior medical staff on the key areas of good prescribing; to reduce harm to patients as a result of poor prescribing; and to work in collaboration with the local hospital pharmacist to promote sustainability of this project. In addition to this, to continue regular audit of the treatment sheets on the paediatric ward to audit the effect of this project.
An assessment of the problem was undertaken in a one day audit looking at the prescription charts (treatment sheets) of all inpatients on the paediatric ward.
I undertook a one day audit looking at the prescription charts (treatment sheets) of all inpatients on the paediatric ward. I found:
Only 17% of treatment sheets were correct.
Only 4% of treatment sheets had dates indicating when the drugs had been started.
Only 2% of treatment sheets had signatures for the drugs prescribed.
There were a significant number of drug errors, nearly all the errors made were prescribing the drugs, which were most commonly prescribed – IV antibiotics and paracetamol.
To understand the causes for this a discussion with the staff involved was undertaken, a multitude of factors leading to these errors were identfied. One of the most significant was that their undergraduate education did not provide any teaching on prescribing or medication harm.
The main changes required in this setting were education and a behavioural change from the prescribing clinicians. I shared the results on the initial audit of prescribing with the staff members present at the weekly CME session, and formally submitted it to the head of department for paediatrics.
An intervention was undertaken in the form of a joint teaching session on the principles of prescribing. This session had two parts – a presentation on good prescribing, and practical prescribing scenarios. Following this session, clinicians were informed that I would be examining the prescribing charts once a week, on an unspecified day, and on a Friday I would give a small prize to the best prescriber of that week. This is clearly at odds with how we would undertake an improvement project in the UK.
The project involved Kenyan trained Medical Officer, Clinical Officer Interns, Medical Officers and the hospital pharmacist.
These changes had a significant effect on prescribing. The reduction in prescribing errors meant there was a reduced risk of harm to individual patients. The clinicians had also benefited from the education, commenting “no one has taught us to do this before”, “we can use this in other departments too”.
The next steps to be put in place are that the local pharmacist has continued to deliver the teaching at each 12 week changeover of junior medical staff promoting the importance of safe prescribing, and giving the tools to the staff to facilitate this.
This work was undertaken in a low-resource setting. The project did not have any formal endorsement. It was done in conjunction with the pharmacist at the hospital.