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SP1 Using kotter’s change model to reduce paediatric prescribing errors
  1. Ashifa Trivedi,
  2. Richa Ajitsaria,
  3. Tristan The Bate
  1. Hillingdon Hospitals NHS Foundation Trust


Aim We describe a quality improvement project to reduce the paediatric prescribing error rate on a paediatric ward in a district general hospital. The project is called STAMP (Safe Treatment and Administration of Medicine in Paediatrics) and was started in 2016. In 2017 the local error rate was 5.2% (average monthly error rate) and decreased to 3.8% in 2019. Despite these earlier interventions the error rate has since not improved and in 2020 the error rate increased to 4.4%. Using Kotter’s Change Management model1 our aim was to decrease the prescribing error rate by 20% (from 4.4% to a target of 3.5%) by August 2021.

Method The paediatric pharmacy team collected weekly error data from December 2016 to August 2021. Reynolds et al2 report that hospital doctors are often unaware of their errors. As a result of this Reynolds et al developed a questionnaire to better understand the attitudes and perceptions of prescribers with regards to prescribing errors. Permission was asked if we could use the questionnaire locally and this was given to us.

The questionnaire was emailed to all paediatric prescribers, including non-medical prescribers, in September 2020. 97% (30/31) of respondents felt that the number of prescribing errors can be reduced. However, 65% (20/31) of prescribers said that they feel they do not make a significant number of prescribing errors. The results of the questionnaire helped us to better understand why prescribing errors happen and changed the way errors were fedback to prescribers. Interventions included paediatric pharmacy teaching at induction, reporting of weekly error rate, ‘spot the error’ quizzes and individual feedback given to prescribers. Prescribers were asked if they were happy to receive feedback via email if we were not able to give face to face feedback.

Results The project has been able to achieve a reduction in error rate to an average of 2.1% (from September 2020 – July 2021) compared to an average error rate of 4.4% the previous year. The aim was to reduce the error rate to 3.5% or below and we have been able to achieve this constantly since October 2020. There have been four weeks where there have been no errors on the ward.

Conclusion This project demonstrates that Kotter’s model can successfully be used in healthcare to reduce prescribing errors. Our most successful interventions have been paediatric pharmacy teaching at induction and emailing individual feedback to prescribers.


  1. Kotter JP. Leading change. Boston, MA: Harvard Business Review Press; 2012.

  2. Reynolds M, Jheeta S, Benn J, et al. Improving feedback on junior doctors’ prescribing errors: mixed-methods evaluation of a quality improvement project. BMJ Quality & Safety 2017;26:240-247.

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