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45 Paediatric prescription errors: an ongoing quality improvement project
  1. Thomas Roe
  1. University of Plymouth


Aims Drug prescription errors can present a significant danger for all patients; however children are at greater risk given the pharmacokinetic differences between this population and adults. Subsequently, drug dosages are based on weight, age, or surface area which can invite errors. Working without appreciation for this complexity can have devastating clinical implications, and therefore, drug prescription charts are standardised for adults and children separately.

The prescription charts of a paediatric department in a district general hospital (DGH) were audited to determine whether the standards of the British Pharmacological Society were being met, and consequently, a quality improvement project was developed.

Methods Data from 13-15 drug prescription charts was collected from paediatric in-patients at the DGH. Five key improvement areas were identified and an intervention was delivered via an oral presentation to all paediatric staff. In addition, a poster was distributed identifying key areas for improvement before re-auditing two weeks later. Confidentiality was never breached. Initial audit drug charts n=15, drug prescriptions n=65. Re-audit drug charts n=14, drug prescriptions n=88.

Results Results are written as percentages of correct responses for pre- to post-intervention, with p-values outlining any statistically significant differences. Allergy signature (47% to 64%, p>0.05), prescriber name (26% to 38%, p>0.05), prescriber GMC/bleep number (63% to 59%, p>0.05), duration for regular medication (13% to 34%, p>0.05), and correct amendment of errors (20% to 33%, p>0.05).

Conclusion Although the results demonstrate non-statistically significant improvements in error rate, it outlines that the dissemination of common mistakes can result in a small improvement in error incidence, thus improving patient safety. Furthermore, there appears to be a perceived cultural barrier for junior medical staff and nurses to identify senior clinician mistakes, particularly if they are from different departments. These factors are being addressed and recycling of this quality improvement project is currently on-going.

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