An audit of electronic prescribing and administration of paediatric parenteral nutrition
Introduction A paediatric pharmacist orders paediatric parenteral nutrition (PN), following discussion with the gastroenterology Registrar or Consultant. The PN is then prescribed on the electronic drug chart by a rotational gastroenterology SHO. Nursing staff administer the PN as per electronic prescription. Last year, there were nine reported PN prescribing or administration incidents which affected patient care at this Trust.
Aim To establish whether paediatric PN regimens were correctly documented in medical notes, prescribed on electronic drug chart, endorsed on insert for notes (a written confirmation of the bag's constituents) and administered as per electronic prescription.
Standards 1. 100% of PN regimens (amount to be administered and number of hours of infusion) are documented daily in the patient's notes, as discussed at ward round.
2. 100% of PN regimens are clinically appropriate for the patient each day.
3. 100% of electronic PN prescriptions have the correct date, infusion volume, infusion rate and number of hours of infusion.
4. 100% of PN insert for notes are endorsed with amount to be administered, number of hours of infusion and signed by prescriber.
5. 100% of infusion pumps are set to run at the correct rate as per electronic prescription.
Method Data was collected prospectively for 5 weeks. All paediatric in-patients on PN were included. On weekdays, patient medical notes were checked for documentation of regimens. Each weekday morning, PN infusion pump rates were checked. Each weekday afternoon, electronic prescriptions were screened, prior to administration. PN for the weekend was prescribed and screened in advance on Friday. PN insert for notes were checked for endorsement and prescriber's signature.
Results There were 10 patients in total, with 3–7 paediatric in-patients on PN at any one time. There were 159 electronic prescriptions and 154 inserts for notes. Patient medical notes were checked for documentation 125 times. Infusion pumps were checked 108 times. All prescribed PN regimens were clinically appropriate for the patients each day (standard 2). All infusion pumps were set to run at the correct rate by nursing staff (standard 5). PN regimens were fully documented in patient notes only 42% (53/125) of the time (standard 1). Only 68% (105/154) of insert for notes were endorsed and signed by the prescribing doctor (standard 4). 18% (29/159) of electronic prescriptions were prescribed incorrectly (standard 3). 28 incorrect prescriptions were picked up by the pharmacist and amended prior to administration.
Conclusions The audit demonstrated that documentation of PN regimens in medical notes and endorsement of PN insert for notes by prescribers was poor and needs to be improved. There were 29 electronic prescribing errors, of which 97% (28/29) were corrected by the pharmacist prior to administration. This audit highlighted that formal training for doctors new to electronic PN prescribing is required. A re-audit could be carried out after implementation of this. An electronic prescribing guideline is now available. The results have been presented at the paediatric clinical governance and gastroenterology educational meetings.