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P15 Using prescribing nudges to reduce medication errors: paracetamol on paediatric intensive care
  1. Jenny Gray1,
  2. Nicole Aubrey2,
  3. Emma Hipkin2,
  4. Nicholas Jones3
  1. 1Bristol Children’s Hospital
  2. 2University of Bath
  3. 3University Hospitals Bristol


Aim Paracetamol is widely available and its safety profile is relatively good. However, the risk associated with a paracetamol overdose is much greater in a neonate than that associated with an adult.

In 2018, 8% of paediatric medication errors related to the use of paracetamol, including three 10x overdoses. These irregular but serious risks are difficult to manage over time due to degradation of heightened awareness. The aim of this project was to improve the prescribing quality of IV paracetamol on PICU and prevent recurrence of a 10-fold overdose by the implementation of multi-level changes.

Method Electronic prescribing (EP) has been in use on our unit since 2016. Small changes (prescribing nudges) in the configuration of the EP system can be used to improve prescribing quality. Forced functions, automation and standardisation have been found to be more effective in this than more traditional education and training methods.1 2

The changes implemented in January 2019 were as follows:

  • Forced function: All paracetamol prescriptions for patients under 1 year of age were capped at 180 mg (change from 1000 mg). The prescriber could not enter a number greater than 180 mg.

  • Automation: All oral paracetamol prescriptions were changed to automatically prescribe 15 mg/kg 6 hourly regardless of age (previously 2 different options requiring the prescriber to input dose and frequency according to formulary directions).

  • Standardisation/simplification: All oral paracetamol prescriptions were rationalised to a single option with automatic dose and frequency as above (previously 2 different options unnecessarily).

  • Reminder/rule: A rule of ‘Consultant Approval’ was added to all intravenous paracetamol prescriptions. The intention of this was for a review of the prescription before use to ensure appropriate use and dose/frequency. This could not be forced, so an education package was launched across the unit by the quality improvement group.

Prescription details were downloaded from the EP system for 3 month periods pre and post changes. he data was audited by pharmacy undergraduate students for prescribing accuracy.

Results The forced function, automation and standardisation options were implemented with 100% compliance. The ‘consultant approval’ rule was followed in 23% of cases. Consultant review led to a 58.6% reduction of IV paracetamol prescriptions on the unit and zero prescriptions for the first 2 months post implementation. The usage of oral paracetamol increased accordingly. This change corresponded to an overall reduction rate of 41.7% for intravenous paracetamol prescriptions.

Conclusions This project demonstrates how changes that increase automation within prescribing can reduce error and that implementation is more successful than education. A limitation of our data analysis was that we did not measure the effect on pain relief or pain scores in the patients who did not receive IV paracetamol compared to those who did.


  1. Cafazzo JA, et al. From discovery to design: the evolution of human factors in healthcare. Healthcare Quarterly 2012; 15: 24–29.

  2. Patel Ms, et al. Nudge units to improve the delivery of healthcare NEJM 2018; 378: 214–216.

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