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P02 Strive to prescribe and do no harm
  1. Ebraheem Junaid,
  2. Kopila Rai,
  3. Wynn Aung,
  4. Sarah Driscoll,
  5. Laura Roe
  1. University Hospitals of North Midlands NHS Trust (UHNM)


Aims Prescribing medication is a common intervention and hence prescribing errors are not uncommon events. From the literature 13% of paediatric prescriptions contain errors1 and recently it was estimated that 66 million of the 237 million prescription errors had potentially clinically significant outcomes.2 This has been highlighted following a recent critical incident and, as part of the learning recommendations; a multidisciplinary team (MDT) approach was formed to improve departmental prescribing education. The aim was to reduce the number of prescribing errors, therefore reducing harm to patients, and improving patient care. This was achieved through the joint efforts of trainees and ward pharmacist by developing robust evidence-based teaching not only at induction but as rolling sessions throughout the year which, due to COVID-19 restrictions, was delivered virtually. In conjunction there was also a revision of the induction paediatric prescribing test, regular review of the number of prescribing error incidents and drug chart audits with cycle completion and implementation of changes. The teaching programme and audits were started in December 2020 and are on-going.

Methods From December 2020 to May 2021, audits were undertaken initially using the RCPCH Paediatric Prescribing Error tool.3 We later revised the audit tool to also include the standards defined in our hospital inpatient prescribing policy. 30 random drug charts from across three paediatric inpatient wards were analysed every month with the aim to achieve greater than 90% in each standard (taking into account a baseline level of human error) and then to maintain this over time. To achieve this, learning from the audit was fed back to all members of the team via regular electronic and visual/verbal reminders and the teaching programme was amended to include troublesome topics. Adverse incidents were reviewed and teaching from this was also included in the teaching programme.

Results Since December 2020, it took six months for the number of incidents due to prescribing errors to reduce from 14 in six months (December 2020-May 2021) to 10 in six months (June-November 2021). Audit results showed that since December 2020 we were scoring >90% in 3 out of the 10 domains. Three months into the teaching programme this improved to 4 out of 10 of the domains and at six months, 6 out of 10 domains. When re-audited with our revised audit tool, we achieved >90% initially in 10 out of 16 domains and then consistently maintained our standards across 11–12 out of 16 domains over a four-month period (October 2021-January 2022).

Conclusions This project has shown that despite a global pandemic, a combination of innovation, education, technology, multidisciplinary skills and MDT working can implement and embed change to improve patient safety. When considering the bigger picture, we recognise this is a small part of the larger systemic processes that can influence medication errors and that with perseverance, we can aim to reduce the risk of adverse events due to medication errors and therefore provide the best care for our patients.


  1. Ghaleb MA, Barber N, Franklin BD, et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 2010;95;113–118.

  2. Elliot RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety 2021;30:96–105.

  3. RCPCH Paediatric Prescribing Error Audit Tool.

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