title: THE DEVELOPMENT OF A QUALITY IMPROVEMENT SYSTEM TO MONITOR, ASSESS AND FEEDBACK PRESCRIBING ERRORS IN PAEDIATRIC INTENSIVE CARE.
abstract: BACKGROUND
  Prescribing errors are a major contributing factor to many medication errors and therefore are at the forefront of strategies to reduce errors and improve patient safety.1 Many paediatric intensive care units have attempted to implement "Zero Tolerance Prescribing" to improve standards of prescribing. However the enforcement of these standards can be difficult and time consuming with varied success.2 AIMS: The aim of this project was to reduce prescribing errors by adapting a previous study3 that had developed a novel way of analysing, interpreting and publishing prescribing audit data. This would allow us to promote an educational approach to our prescribing audits and allow us to provide constructive feedback and learning points for all prescribers on the unit. The main element would be to use a spreadsheet to automate this process to reduce the time required to produce the reports.
  
  
  METHODS
  Prescriptions were assessed over a 2 week period according to local "Zero Tolerance" standards. An Excel spreadsheet was designed to provide individual feedback forms for prescribers. This contained data such as error rates and types, examples of specific errors and anonymous results from other prescribers for comparison. Additional reports were also generated to create posters that could be displayed around the unit and discussed at clinical governance meetings. This cycle was repeated after approximately 1 month.
  
  
  RESULTS
  In total 376 and 275 prescription were assessed in each cycle. The overall unit mean error rate remained consistent between the two cycles at 12.5% and 13.0% respectively. In prescribers who prescribed at least 5 items in both cycles (n=7), there was a decrease in error rate over 5.9% from cycle 1 (M=15.3, SD=14.6) compared with cycle 2 (M=9.4 SD=7.3); t(6)=1.1710 p=0.29 although this was not statistically significant using a paired t-test.
  
  
  CONCLUSIONS
  The audits that we completed did not show any reduction in mean error rate. However, when we looked more closely at the data we had gathered, it was noticeable that there was a reduction when comparing individuals between each cycle. This demonstrated that our system of feedback for prescribers did lead to changes in practice and improvements.The main limitation of our method was the lack data for each prescriber and that prescribers had varied total prescribing volume that resulted in easily skewed data.
authors.affiliation: Central Manchester University Hospitals NHS Foundation Trust.
authors.forename: Stephen
authors.initials: S
authors.lastname: Morris
authors.affiliation: Claire Rivett Newcastle Upon Tyne Hospitals NHS Foundation Trust.
authors.forename: Claire
authors.initials: C
authors.lastname: Rivett
keywords: Abstract; Oral