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An audit of prescribing errors in neonates and paediatrics
  1. M O'Meara,
  2. E Lyons
  1. Pharmacy Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK


Aims An online system known as ‘Datix’ is utilised locally for the voluntary reporting of prescribing errors. The actual rate of prescribing errors in neonates and children is unknown. This re-audit aimed to investigate the incidence and nature of prescribing errors in this patient group. Drugs most commonly associated with prescribing errors were identified and the results compared to previous audit and national findings. The clinical significance of reported errors was determined.

Standard 0% of prescriptions contain a prescribing/transcribing error

Methods Data was collected prospectively by ward pharmacists over 2 weeks, on six paediatric wards and one neonatal ward. The prescribing errors were recorded using a validated list of paediatric prescribing error scenarios.1 Data were collated and analysed using Microsoft Excel. The clinical significance of reported errors was evaluated by members of the multidisciplinary team using a validated visual analogue scale of (0–10) where 0 represents an error with no potential effect and 10 an error that would result in patient death.2

Results 1411 new prescriptions were written and 500 transcribed. The audit did not meet its standard. 125 prescribing errors were identified, including 30 transcription errors. The prescribing error rate was 6.5% (125/1911). The overall prescribing error rate excluding transcription errors was 6.7% (95/1411).

The error rates were compared between specialities. Paediatric neurology reported the highest error rate (14.3%), High rates were observed in critical care areas, high dependency (13.6%) and intensive care (10.5%).

Medicines prescribed intravenously accounted for 39% of prescribing errors whilst 31% were in medicines prescribed via the oral route. Errors related to incorrect dosing accounted for 45% of those reported. The greatest number of errors were reported in children <4 years (45%). Drugs most commonly associated with prescribing errors were (n=125): paracetamol (14.4%); gentamicin (6.8%); morphine (6.8%) and tacrolimus (5.1%).

0 errors were reported on the ‘Datix’ system.

The clinical significance was evaluated for 109 reported errors. 4.5% were found to have a mean clinical significance rating of >6/10, 59% had a mean rating of >3 and ≤6/10 and 33% had a mean rating of ≥0 and ≤3/10.

Conclusions The reported error rates represent a 2.4% increase from the 2011 audit but is significantly lower than rates reported in the literature.3 4 The results obtained will be utilised to target drugs and specialities associated with the highest error rates and the most clinically significant errors. Further work is indicated to improve error reporting on ‘Datix’.

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