title: Personalised performance feedback reduces narcotic prescription errors in a NICU.
abstract: OBJECTIVE
  Neonates are at high risk for significant morbidity and mortality from medication prescribing errors. Despite general awareness of these risks, mistakes continue to happen. Alerts in computerised physician order entry intended to help prescribers avoid errors have not been effective enough. This improvement project delivered feedback of prescribing errors to prescribers in the neonatal intensive care unit (NICU), and measured the impact on medication error frequency.
  
  
  METHODS
  A front-line multidisciplinary team doing multiple Plan Do Study Act cycles developed a system to communicate prescribing errors directly to providers every 2 weeks in the NICU. The primary outcome measure was number of days between medication prescribing errors with particular focus on antibiotic and narcotic errors.
  
  
  RESULTS
  A T-control chart showed that the number of days between narcotic prescribing errors rose from 3.94 to 22.63 days after the intervention, an 83% improvement. No effect in the number of days between antibiotic prescribing errors during the same period was found.
  
  
  CONCLUSIONS
  An effective system to communicate mistakes can reduce some types of prescribing errors.
authors.affiliation: Department of Pediatrics, Nemours Neonatology, AI duPont Hospital for Children, Wilmington, Delaware, USA.
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Sullivan
authors.forename: Sanghee
authors.initials: S
authors.lastname: Suh
authors.forename: Heather
authors.initials: H
authors.lastname: Monk
authors.forename: John
authors.initials: J
authors.lastname: Chuo
mesh_terms: D000900:Anti-Bacterial Agents; D054869:Clinical Audit; D002983:Clinical Competence; D017723:Drug Utilization Review; D004650:Employee Performance Appraisal / Q000379:methods*; D030141:Feedback, Psychological; D006801:Humans; D007324:Institutional Management Teams; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D050316:Medical Order Entry Systems / Q000592:standards*; D008508:Medication Errors / Q000517:prevention & control* / Q000706:statistics & numerical data; D009294:Narcotics; D010818:Practice Patterns, Physicians' / Q000592:standards; D058996:Quality Improvement; D017751:Safety Management; D013192:Staff Development / Q000379:methods
chemical_list: D000900:Anti-Bacterial Agents; D009294:Narcotics