To determine the proportion of patients:
▶ receiving the recommended dose of gentamicin (based on most appropriate guideline)
▶ having first blood levels of gentamicin measured and recorded at correct date/time
▶ having details completed on Green Stickers (to document levels on drug charts for patients on therapeutic drug monitoring (TDM) drugs).
Method A data collection form was designed and used for all gentamicin prescribing and monitoring activity on neonatal and paediatric wards at Lewisham Hospital over 4 weeks. Data collected included: age, weight, dose, gentamicin levels, time levels were taken and details completed on the Green Sticker.
Results 50 patients were identified as having received gentamicin on the neonatal and paediatric wards during the study period.
4/50 (8%) of patients received 7 mg/kg daily (as per BNF-C) instead of 6 mg/kg daily (as per local paediatric formulary).
If all levels had been taken and documented appropriately, there should have been 90 Green Stickers attached and completed in full on the patients' drug charts. 59/90 (65%) green stickers were attached to the patients' drug charts.
31 gentamicin levels were measured and available to view on the computer that were not recorded on the drug charts.
Of the 59 stickers that were attached to drug charts, there were 101 errors in terms of missing information.
Conclusion For general medical and surgical paediatric patients, the local paediatric formulary recommends 6 mg/kg daily and the BNF-C recommends 7 mg/kg daily. There is confusion over which dose of gentamicin should be prescribed. Discussions with the paediatric team have resulted in a change in the local guideline to 7 mg/kg gentamicin for all children (not neonates) unless they have specific conditions such as cystic fibrosis, endocarditis or renal impairment.
There are five different paediatric guidelines being used at Lewisham and each recommends checking the first trough level at different times. Discussions with the paediatric team have resulted in a change in practice – now all gentamicin levels are checked before the second dose is due, to ensure that the drug is being eliminated appropriately.
This audit demonstrated that completion of Green Stickers is poor. Further education is needed to explain the importance of completing these in full. If no record is made of when blood samples are taken, it is difficult to interpret the levels. Doses of gentamicin are administered to patients without any documentation that the levels have been checked.