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  1. Gareth Kitson
  1. Imperial College NHS Healthcare Trust


    Aim Since the introduction of NICE guidance for Early Onset Neonatal Sepsis (EONS)1 in August 2012, the number of locally reported prescribing and administration errors involving gentamicin has increased. This guideline introduced a new, unfamiliar regimen to staff working on the Neonatal Units and Postnatal wards. Analysis of the errors suggested 36 hourly frequency of gentamicin contributed to the errors due to the complexities of prescribing on the paper drug chart. Our aim was to reduce errors involving gentamicin through the introduction of a Microsoft Excel® based electronic prescription chart.

    Method Local medication incident reports for gentamicin were analysed from 1st September 2013 to 3rd October 2014 (prior to the introduction of the new prescription chart). The new prescription chart was introduced from 5 January 2015. Incident reports continued to be monitored until 30th July 2015.

    The electronic prescription has specific patient demographics, which need to be completed by the prescriber. The spreadsheet calculates the dose (rounded to give a practical administration volume) and generates a prescription with shaded boxes for the times which do not require administration. Built in to the spreadsheet are features including selecting the correct time for administration (based on the time of an initial dose given) and the dates and times that therapeutic drug monitoring (TDM) is due.

    The prescription is completed by the neonatal doctors, printed out, signed and stapled to the drug chart. The drugs are administered by midwives on the postnatal wards or nurses in neonatal areas.

    Each gentamicin dose must be signed for by the prescriber before each dose is given, thus prompting the medical team to review any TDM necessary. The prescription lasts for 7 days and then the frequency of gentamicin changes to 24 hourly so the standard chart is used.

    Results Pre-implementation, 18 prescribing errors and 17 administration errors were reported over a 13 month period. Post implementation, there were 8 prescribing errors and 12 administration errors over 7 months. The impact on reported error numbers seems minimal. However, review of error reports suggests that the types of errors have changed. Post-implementation, there were no reports about incorrect frequency, poorly completed prescriptions or TDM errors. Post implementation, the errors now focus around practical aspects of using the prescription chart, for example, ensuring the prescription is attached to a drug chart or a missing signature to say that the gentamicin level had been taken and checked and therefore, the dose had been slightly delayed.

    Conclusion Historical medication error reports are likely to represent under-reporting. Due to heightened awareness following implementation, it is suggested that almost all errors are being reported. Our results suggest that the introduction of an electronic prescription has reduced the number of error reports resulting in harm to patients and work is on-going to ensure the effectiveness of the prescription chart is maintained. It will also be developed further, in order to target and reduce the new errors which have been reported.

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