Intensive Care Medicine

, Volume 38, Issue 9, pp 1532–1538 | Cite as

Impact of an intervention to reduce prescribing errors in a pediatric intensive care unit

  • Amalia Martinez-AntonEmail author
  • J. Ignacio Sanchez
  • Lidia Casanueva
Pediatric Original



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.


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.


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.


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


Medication errors Prescribing error Intensive care unit Pediatrics 



We acknowledge the financial support received from the Biomedical Research Foundation of the Hospital Universitario 12 de Octubre de Madrid.

Supplementary material

134_2012_2609_MOESM1_ESM.doc (28 kb)
Supplementary material 1 (DOC 28 kb)


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Copyright information

© Copyright jointly held by Springer and ESICM 2012

Authors and Affiliations

  • Amalia Martinez-Anton
    • 1
    Email author
  • J. Ignacio Sanchez
    • 2
  • Lidia Casanueva
    • 2
  1. 1.Department of Pediatrics, Pediatric Critical Care UnitHospital Universitario Fundación Jiménez DíazMadridSpain
  2. 2.Department of Pediatrics, Pediatric Critical Care UnitHospital Universitario 12 de OctubreMadridSpain

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