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Zero tolerance prescribing

Introducing a policy of zero tolerance to prescribing errors in a children’s hospital in Brighton.

The problem

We identified that there was a constant stream of ‘low grade’ prescribing errors in the monthly multidisciplinary ‘Child Patient Safety and Quality’ meeting. We needed to change the accepted culture, among doctors, when it came to prescribing. By not accepting the ‘small’ errors the hope was that the bigger errors, which may cause the patient harm, would not occur. So, if you prescribe incorrectly, no matter how small the error or what grade of doctor you are, you will be made aware of the error in the hope that you are less likely to repeat the mistake.

Aims

1. To inform any prescriber of their incorrect prescriptions (with feedback about why the prescription was incorrect), as quickly as possible, by a Consultant.

2. To see if genuine, constructive feedback from a senior colleague, reduced the number of prescribing errors made, over time. The assumption was that prescribers did not make errors deliberately.

Making the case for change

I explained to all the doctors the importance of taking a zero tolerance approach. All agreed it was a good idea. They were happy for any prescribing error to be photographed (with error highlighted) by the pharmacist. I would ensure that the picture got to the prescriber via me, as the Consultant. All the nurses, pharmacists and doctors were made aware of the project before we started.

Your improvement

Over the four month study period we found an 86% reduction in prescribing errors, as identified by the pharmacists that review all the inpatient drug charts every weekday morning. Please see attached the graph and two photos to give an example of ‘zero tolerance’ prescribing errors. Please click on the graph below to enlarge.

 

Learning and next steps

It doesn’t take long to change the accepted norm, once everyone is on board. However it is difficult to sustain the improvement in the face of junior doctors changing every three to six months. It is also very labour intensive for a single Consultant to ensure all the errors identified get to the relevant individual as quickly as possible. Could this be developed into an app where the ‘picture taker’ (pharmacist) is able to click on the app and the images go to all the relevant individuals instantly?

Quality assurance/MHRA Registration

Project approved by the local Trust via the monthly Child, Patient Safety & Quality meetings.