Aim A level 3 tertiary neonatal unit with a capacity of 40 cots providing intensive care, high dependency care, special care & transitional care services, had 18 gentamicin errors reported between January and June 2017, with 84% errors occurring at prescribing and 16% errors in administration. The majority of errors (67%) were due to the complexity of calculating a 36-hourly time interval between doses. A quality improvement project was undertaken with the aim of reducing the number of gentamicin errors on the unit over a 3 month period.

Method An overview of all gentamicin errors were presented to the multidisciplinary team (MDT) with a view of gathering ideas for improvement to ensure a team based approach. An action plan was put in place in line with National Patient Safety Agency (NPSA) recommendations¹ and initiated in July 2017 based on a plan-do-study-act (PDSA) model.

Results The PDSA cycles included:

1. a simplified and standardised dosing interval for dosing of gentamicin after the first dose.

2. an updated local monograph with dosing intervals and example prescription.

3. posters displayed in prescribing areas to promote safe and focused prescribing.

4. a feedback session to the full MDT team regarding improvements made and further feedback.

5. ensure compliance with policy by promoting updated guideline & on going error monitoring.

6. consideration of alternative lower risk antibiotic in low risk babies.

7. incorporation of gentamicin prescribing exercise as part of the new doctor induction. The following interventions will be evaluated in 3 months using Datix reported errors before and after implementation. Sequential PDSA cycles will then be conducted for learning and improvement.

Conclusion A team based approach, using open communication with regular feedback and review is essential in order to improve the quality of prescribing and gain engagement from medical and non-medical prescribing colleagues. Further audit will be undertaken on monthly basis to evaluate the implementation of improvement measures.