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Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit

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Abstract

Objective

To identify and reduce medication-prescribing errors by introducing systematic physician education and post-cardiac surgery admission prescription forms.

Design

Errors were defined as: incomplete prescriptions; potential adverse drug events (ADEs), i.e. either intercepted or non-intercepted incorrect prescriptions not resulting in an ADE; and incorrect prescriptions that resulted in ADEs. Two baseline blinded pre-intervention data collection periods of 4 weeks and 1 week were followed by implementation of a post-cardiac surgery templated physician order and prescription form and systematic physicians' education. Twelve post-intervention data collections of 1-week duration were completed over a 3-year period and were either blinded or informed with reinforcement of physicians' education.

Setting

Tertiary paediatric cardiac intensive care unit.

Results

A total of 3648 prescriptions were evaluated at baseline (mean ± SD of 687 ± 8 per week) and 811 ± 129 prescriptions during each post-intervention period. Total baseline errors of 16.8% decreased to 8.4% after the first blinded data collection and to 4.8% at the final data collection (p < 0.001). The occurrence of incomplete prescriptions fell from 15.3% at baseline to 3.6% at final data collection (p < 0.001); intercepted potential ADEs fell from 1.3% to 1.1%; non-intercepted potential ADEs fell from 0.17% to zero; and post-operative prescribing errors fell from 44% to 4.6% (p < 0.001), with the major reduction seen in incomplete prescriptions.

Conclusion

The incidence of incomplete prescriptions significantly improved with education of physicians and use of post-cardiac surgery templated physician order and prescription forms. There was no impact on potential ADEs.

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Authors and Affiliations

  1. Department of Cardiology, Children’s Hospital, Boston, MA, USA

    Margarita K. Burmester, Ravi R. Thiagarajan & Peter C. Laussen

  2. Department of Pharmacy, Children’s Hospital, Boston, MA, USA

    Roger Dionne

  3. Paediatric Intensive Care Unit, Royal Brompton Hospital, Sydney Street, SW3 6NP, London, UK

    Margarita K. Burmester

Authors
  1. Margarita K. Burmester
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  2. Roger Dionne
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  3. Ravi R. Thiagarajan
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  4. Peter C. Laussen
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Corresponding author

Correspondence to Margarita K. Burmester.

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Burmester, M.K., Dionne, R., Thiagarajan, R.R. et al. Interventions to reduce medication prescribing errors in a paediatric cardiac intensive care unit. Intensive Care Med 34, 1083–1090 (2008). https://doi.org/10.1007/s00134-008-1054-3

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  • DOI: https://doi.org/10.1007/s00134-008-1054-3

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