title: Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit.
abstract: OBJECTIVE
  To identify and reduce medication-prescribing errors by introducing systematic physician education and post-cardiac surgery admission prescription forms.
  
  
  METHODS
  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.
  
  
  METHODS
  Tertiary paediatric cardiac intensive care unit.
  
  
  RESULTS
  A total of 3648 prescriptions were evaluated at baseline (mean +/- SD of 687+/- 8 per week) and 811 +/- 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<0.001). The occurrence of incomplete prescriptions fell from 15.3% at baseline to 3.6% at final data collection (p<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<0.001), with the major reduction seen in incomplete prescriptions.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Cardiology, Children's Hospital, Boston, MA, USA. m.burmester@rbht.nhs.uk
authors.forename: Margarita K
authors.initials: MK
authors.lastname: Burmester
authors.forename: Roger
authors.initials: R
authors.lastname: Dionne
authors.forename: Ravi R
authors.initials: RR
authors.lastname: Thiagarajan
authors.forename: Peter C
authors.initials: PC
authors.lastname: Laussen
mesh_terms: D006348:Cardiac Surgical Procedures; D016009:Chi-Square Distribution; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D006801:Humans; D015278:Intensive Care Units, Pediatric; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D011446:Prospective Studies