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G229(P) Investigating prescribing errors
  1. NJ Bostock,
  2. N Gooding,
  3. M Robertson,
  4. W Kelsall
  1. Paediatrics and Neonataology, Addenbrookes Hospital, Cambridge, UK


Aim The Paediatrics department has been identified as making more prescribing errors than any other. The aim is to help inform methods to reduce prescribing errors by investigating details of prescribing errors made in a Paediatric and Tertiary Neonatal unit and reported in Critical Incident Forms (CIFs).

Method CIFs involving all medication errors in the Paediatric and Neonatal unit, submitted between October 2012 and March 2013, were evaluated.

The patient notes of all CIFs that were classified as ‘prescribing errors’ were obtained, and other CIFs classified as ‘medication errors’ were read. If there was any doubt as to whether the incident involved a prescribing error, rather than an administration or systems error, then the patient notes were also reviewed.

Data was collected on details of error, prescriber identification, grade and specialty, time of day and day of the week the error was made, and actions resulting from the error.

Results 173 CIFs involving medication errors were submitted. On review, 70 were thought to be prescribing errors.

The impact of prescribing errors were categorised as:

  • Severe 0

  • Moderate 1

  • Minor 17

  • None 52

Of these, 65 sets of notes were reviewed. 30 prescribers were identified:

13 Paediatric SHO’s

8 Paediatric SpRs

3 paediatric clinical fellow

2 nurse prescribers

1 GP trainee

2 Other SHO’s

21 prescribers had made one error, eight had made two errors, and one had made three errors

Time of day of the incident, where the time could be reasonably assumed, was difficult to identify.

In hours: 21

Out of hours: 22 (8 at night)

Medicines Involved:

Conclusion The majority of errors surround a few drugs. Focussing on the prescribing of these drugs could help to reduce errors.

Errors are being made by experienced, well-trained and competent medical professionals; it is not a few people making multiple mistakes. The issue of human error, and systems to prevent this, should be considered. We are currently undertaking further research exploring the circumstances surrounding individual errors.

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