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P28 Reducing medication errors – a tripartite approach. small steps – better outcomes
  1. Patel Bhavee,
  2. Isaac Rachel,
  3. Vallabhaneni Pramodh
  1. Morriston Hospital, ABMU Health Board


Aim Paediatric medication errors have everyday potential to cause unintended harm.1 Our aim was to reduce paediatric medication errors on a busy general paediatric medical ward.

Method A prospective audit was undertaken, using an audit form, looking at the number and severity of medication errors from May 2016 to July 2016. The severity of the errors was graded as per the EQUIP study.2 The results were analysed using Microsoft Excel.

Action – A study afternoon was arranged in August 2016 to highlight the common themes behind the medication errors followed by a multidisciplinary brainstorming exercise to gather suggestions on reducing medication errors.

An education package was introduced:

  • Medical – all trainees were asked to complete a mandatory online module designed by the Royal College of Paediatrics and Child Health, which provides an overview of need for safe prescription practice in children and common themes leading to errors. Further teaching was provided in departmental teaching meetings and the lead paediatric pharmacist undertook targeted teaching.

  • Nursing – an in house competency package was developed based around the principles of the ‘5 rights’ of medication administration, the Health Board controlled drug policy and the All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal. All staff were encouraged to complete this package. Through one on one sessions with the practice development nurse, staff were coached to follow the five Rs of Right Drug, Right Dose, Right Time, Right Route, and Right Patient.

  • Pharmacy – Lead pharmacist introduced an education tool as advocated by Meds IQ called Druggle3 in the department, where at the end of the safety huddle the pharmacist discusses medication interventions on a daily basis that may have happened on the ward. Through this tool formative education was provided to junior doctors and nurses.

  • Re–audit – After six months of intensive education, a prospective re–audit was undertaken between December 2016 and February 2017 using an audit form. The results were analysed using Microsoft Excel.

Results The results showed that 88.6% (141/159) of children admitted had medication errors. 61.2% (87/141) of errors were minor, 34.7% (49/141) significant, 2.8% (4/141) serious and 1.3% (1/141) potentially lethal.

The results of the re-audit showed that 12.1% (57/470) of children had medication errors. 77.2% (44/57) of errors were minor and 22.8% (13/57) significant. There were no serious or potentially lethal errors reported.

This showed an overall reduction of 76.5% medication errors in the children admitted following the introduction of the education package.

Conclusion The education package through the tripartite approach has achieved a substantial change in the overall rate of prescription errors. We believe medication errors are a significant but preventable cause of harm to children and young people. To ensure this change of practice is sustained we aim to continue the emphasis of education and change management to improve patient safety.


  1. Cass H. Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism. Arch Dis Child2016;101:414–416.

  2. EQUIP final report. [Accessed: 01/08/16].

  3. DRUG-gle (Druggle). [Accessed: 01/08/2016].

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