Background and aims Prescribing errors are common in hospitals. Within Addenbrooke’s, the paediatrics department was found to make more prescribing errors than any other. We aimed to undertake a closed-loop audit of prescribing errors in paediatrics at Addenbrooke’s.
Methods Data was collected from all readily available drug charts on all paediatric wards, once weekly over 6 weeks (first cycle May 2013, second cycle Oct–Nov 2013). Each drug chart was inspected for ‘pharmacist identified’ errors, with minimum standards set in key areas.
Between cycles, interventions included: meeting of senior clinicians and pharmacist; prescriber received standardised email after errors, for discussion with consultant; follow-up of non-responders; audit data and protocol disseminated; paediatric teaching on prescribing.
Results A total of 3436 (first cycle) and 3516 (second cycle) prescriptions were reviewed with 12% and 16%, respectively, containing an error. The commonest error in both cycles was drug name.
Set standards were achieved for correct drug name and dose, but not for legible signature, allergy documentation or weight documentation.
The proportion of drug charts with 0 errors increased in the second cycle. Those with 1–5 errors decreased. However, the proportion of charts with 6+ errors increased (many ‘high error’ charts contained multiple errors by one prescriber).
Conclusions The implemented changes had no significant effect on the rate or type of errors identified. Minimum standards are not being met in some areas. It is possible that a few ‘rogue’ prescribers may be responsible for many errors, in which case targeted strategies may be effective.
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