Aim This Quality Improvement project is the second phase of a long term project to improve the quality of prescribing on the paediatric intensive care unit (PICU). Small adjustments are made to the electronic prescribing (EP) system, known as ‘nudges’, with the aim of improving the quality of prescribing in terms of error rate or user experience.1 2
Intravenous aciclovir is prescribed to most patients admitted to the PICU with suspected meningitis/encephalitis. There is a complicated dosing schedule where the prescriber must decide whether to use body surface area (BSA) or weight to calculate the required dose. Underdosing risks subtherapeutic treatment of a viral encephalitis and overdosing risks acute kidney injury. Within our EP system, dosing by weight can be automated, but dosing by BSA cannot.
A project in 2018 used a ‘nudge’ to alter the order of prescribing options in the drop down menu on the EP system. This reduced the error rate from 26% to 17% by reducing the likelihood of picking the wrong indication for acyclovir.3 However, a re-audit in October to December 2018 found the error rate had crept back up to 32%. Prescribing on the EP system is a multi-step process. Prescribers had to pick ‘aciclovir’ to choose the weight based dose or ‘aciclovir injection 3 month-11 yr‘ to choose the BSA based dosing. When ‘aciclovir’ was picked, this removed the body surface area dosing option from the prescriber’s screen and led them in the direction of an incorrect dose.
Method The intervention for this project was to amalgamate all weight and BSA dosing options for acyclovir within the EP system, and then order them by age so that the prescriber could see all options simultaneously. This change was designed and implemented by our electronic prescribing support pharmacist in April 2019. Pre and post change prescriptions were audited by pharmacy undergraduate students for accuracy using data downloaded from the EP system.
Results The error rate post change was 8% (pre change 32%). The remaining errors reflect transcribing of an incorrect dose initiated outside of the PICU from a referring ward or hospital.
Conclusion This project shows that small, ‘smart’ changes within EP configuration can improve the quality of prescribing.
Future work involves working with the software company to incorporate the ability to automatically calculate the dose based on BSA, further reducing the need for manual calculations. This project would not have been possible without the skills and knowledge of our electronic prescribing support pharmacy team.
Patel MS, et al. Nudge units to improve the delivery of health care. NEJM 2018; 378: 214–216
Cafazzo JA, et al. From discovery to design: the evolution of human factors in healthcare. healthcare quarterly 2012; 15: 24–29
Gunning C, Gray J. Audit of acyclovir prescribing to assess whether changing the order of drop down box options in an electronic prescribing system can reduce prescribing errors. Archives of Disease in Childhood 2019; 104:7
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