Impact of an Intervention to Reduce Prescribing Errors in a Pediatric Intensive Care Unit

Overview

Journal Intensive Care Med

Specialty Critical Care

Date 2012 Jun 13

PMID 22688436

Citations 13

Authors

Amalia Martinez-Anton

J Ignacio Sanchez

Lidia Casanueva

Affiliations

Soon will be listed here.

Abstract

Purpose: To identify and reduce medication prescribing errors in a pediatric intensive care unit (PICU) by means of an educational program designed to improve medical prescriptions.

Methods: Before-after interventional study in a tertiary-level PICU. Handwritten prescriptions were prospectively collected: 2,228 during period 1 and 1,791 during period 2. In both periods elements of good prescribing practice including error indicators and quality indicators were studied. The interventional program included four measures: standardization of prescription sources, pocket tables with dosing guidelines, an updated prescription protocol, and an educational program on correct prescribing.

Results: The prescribing error (PE) rate decreased from 34.2 to 21.7 % after the intervention. Lack of administration route was considered separately for its high prevalence, 30 and 20.8 % of prescriptions, respectively. The most frequent error was presence of some illegible element (59 %). Legibility was the element of prescription experiencing the greatest reduction in error rate, from 4.1 % of prescriptions with one or more illegible elements in period 1 to 0.2 % in period 2. Tenfold overdosage decreased from two cases in period 1 to one case in period 2. The attending physician and on-call physician were associated with more PEs in both periods. The number of prescriptions with two or more errors decreased from 3.1 to 0.7 %. Errors reaching the patient were scarce, 14 (0.63 %) in period 1 and 6 (0.34 %) in period 2, without adverse events.

Conclusions: Implementation of an educational program for physicians may significantly reduce the prescribing error rate in a PICU.

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References

Wilson D, McArtney R, Newcombe R, McArtney R, Gracie J, Kirk C . Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr. 1998; 157(9):769-74. DOI: 10.1007/s004310050932. View

Leape L, Bates D, Cullen D, Cooper J, Demonaco H, Gallivan T . Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA. 1995; 274(1):35-43. View

. Prevention of medication errors in the pediatric inpatient setting. American Academy of Pediatrics. Committee on Drugs and Committee on Hospital Care. Pediatrics. 1998; 102(2 Pt 1):428-30. View

Warrick C, Naik H, Avis S, Fletcher P, Franklin B, Inwald D . A clinical information system reduces medication errors in paediatric intensive care. Intensive Care Med. 2011; 37(4):691-4. DOI: 10.1007/s00134-010-2126-8. View

Otero Lopez M, Codina Jane C, Tames Alonso M, Perez Encinas M . [Medication errors: standarizing the terminology and taxomany. Ruiz Jarabo 2000 grand results]. Farm Hosp. 2003; 27(3):137-49. View

Colpaert K, Decruyenaere J . Computerized physician order entry in critical care. Best Pract Res Clin Anaesthesiol. 2009; 23(1):27-38. DOI: 10.1016/j.bpa.2008.07.002. View

Vincer M, Murray J, Yuill A, Allen A, Evans J, Stinson D . Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child. 1989; 143(6):737-40. DOI: 10.1001/archpedi.1989.02150180119032. View

Raju T, Kecskes S, Thornton J, Perry M, Feldman S . Medication errors in neonatal and paediatric intensive-care units. Lancet. 1989; 2(8659):374-6. DOI: 10.1016/s0140-6736(89)90548-5. View

McCarney R, Warner J, Iliffe S, Haselen R, Griffin M, Fisher P . The Hawthorne Effect: a randomised, controlled trial. BMC Med Res Methodol. 2007; 7:30. PMC: 1936999. DOI: 10.1186/1471-2288-7-30. View

10.

Folli H, Poole R, Benitz W, Russo J . Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics. 1987; 79(5):718-22. View

11.

Jonville A, Autret E, Bavoux F, Bertrand P, Barbier P, Gauchez A . Characteristics of medication errors in pediatrics. DICP. 1991; 25(10):1113-8. DOI: 10.1177/106002809102501018. View

12.

Pallas C, de-la-Cruz J, Del-Moral M, Lora D, Malalana M . Improving the quality of medical prescriptions in neonatal units. Neonatology. 2007; 93(4):251-6. DOI: 10.1159/000111530. View

13.

Eisenberg J, Foster N, Meyer G, Holland H . Federal efforts to improve quality of care: the Quality Interagency Coordination Task Force (QuIC). Jt Comm J Qual Improv. 2001; 27(2):93-100. DOI: 10.1016/s1070-3241(01)27009-6. View

14.

Potts A, Barr F, Gregory D, Wright L, Patel N . Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics. 2004; 113(1 Pt 1):59-63. DOI: 10.1542/peds.113.1.59. View

15.

Perren A, Conte P, De Bitonti N, Limoni C, Merlani P . From the ICU to the ward: cross-checking of the physician's transfer report by intensive care nurses. Intensive Care Med. 2008; 34(11):2054-61. DOI: 10.1007/s00134-008-1138-0. View

16.

Dean B, Barber N, Schachter M . What is a prescribing error?. Qual Health Care. 2000; 9(4):232-7. PMC: 1743540. DOI: 10.1136/qhc.9.4.232. View

17.

Hartwig S, Denger S, SCHNEIDER P . Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991; 48(12):2611-6. View

18.

Sutcliffe A . Prescribing medicines for children. BMJ. 1999; 319(7202):70-1. PMC: 1116223. DOI: 10.1136/bmj.319.7202.70. View

19.

Reason J . Human error: models and management. BMJ. 2000; 320(7237):768-70. PMC: 1117770. DOI: 10.1136/bmj.320.7237.768. View

20.

Cimino M, Kirschbaum M, Brodsky L, Shaha S . Assessing medication prescribing errors in pediatric intensive care units. Pediatr Crit Care Med. 2004; 5(2):124-32. DOI: 10.1097/01.PCC.0000112371.26138.E8. View