RT Journal Article
SR Electronic
T1 P37 Audit on the quality of documentation of paediatric prescriptions using electronic prescription charts
JF Archives of Disease in Childhood
JO Arch Dis Child
FD BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health
SP e1
OP e1
DO 10.1136/archdischild-2017-314584.46
VO 103
IS 2
A1 Stilwell Philippa
A1 Sanu Abimbola
YR 2018
UL http://adc.bmj.com/content/103/2/e1.41.abstract
AB Aim The aim of this project is to assess the quality of prescribing on all inpatient prescription charts on the paediatric wards in the hospital against the legal prescribing requirements (as stated in Medicines Act, 1968) and trust prescribing standards (as stated in the hospital's Medicines Management Policy).Methods Ten audit standards were identified, based on Generic Medical Record Keeping Standards (RCP, 2017), which incorporated all the legal and trust prescribing standards. A data collection tool was then designed.A single day prospective prevalence audit was conducted; data was collected on a single day from each of four paediatric wards, using the data collection tool. All staff members were blinded to the standards being assessed.Inclusion criteria: all inpatient prescription charts on the paediatric wards and all medicines prescribed on those charts were included (on the single day where data was being collected).Exclusion criteria: dietary products, total parenteral nutrition, embolism stockings and chemotherapy.Results 100% compliance was achieved on the majority of patient demographics. 100% compliance was achieved in the majority of standards on prescription item analysis and in all standards for fluids prescriptions. 95% of allergy status´ were documented and 93% of these included the severity of allergy. 73% compliance was achieved in the documentation of patient weight. Improvement is also needed in documenting indication and duration of anti-microbials, where only 81% and 46% compliance was achieved, respectively.Conclusion 100% compliance was achieved in many standards (in particular in those which are automated on e-prescribing, for example, patient demographics). More attention is needed to specify the patient´s weight, the allergy status and severity of allergy and the indication and duration of anti-microbials.Comparing with previous audits done when the trust used paper charts for prescribing, electronic prescribing has clearly overall increased adherence to legal prescribing requirements and trust standards which is a significant step towards improving the safety of patient care within the NHS.The results from this audit have been disseminated to remind current users of common prescribing errors. This was done by presenting the results locally and by emailing all departmental staff with the results.Recommendations from this audit include to ensure that all members of staff that have access to electronic prescribing receive the necessary training prior to starting working.Recommendations also include to discuss with pharmacy whether it is possible to make it compulsory to enter weight and allergy status prior to prescribing, with an option for omission in emergency situations.