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Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit

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Abstract

Purpose

To establish the baseline prescribing error rate in a tertiary paediatric intensive care unit (PICU) and to determine the impact of a zero tolerance prescribing (ZTP) policy incorporating a dedicated prescribing area and daily feedback of prescribing errors.

Methods

A prospective, non-blinded, observational study was undertaken in a 12-bed tertiary PICU over a period of 134 weeks. Baseline prescribing error data were collected on weekdays for all patients for a period of 32 weeks, following which the ZTP policy was introduced. Daily error feedback was introduced after a further 12 months. Errors were sub-classified as ‘clinical’, ‘non-clinical’ and ‘infusion prescription’ errors and the effects of interventions considered separately.

Results

The baseline combined prescribing error rate was 892 (95 % confidence interval (CI) 765–1,019) errors per 1,000 PICU occupied bed days (OBDs), comprising 25.6 % clinical, 44 % non-clinical and 30.4 % infusion prescription errors. The combined interventions of ZTP plus daily error feedback were associated with a reduction in the combined prescribing error rate to 447 (95 % CI 389–504) errors per 1,000 OBDs (p < 0.0001), an absolute risk reduction of 44.5 % (95 % CI 40.8–48.0 %). Introduction of the ZTP policy was associated with a significant decrease in clinical and infusion prescription errors, while the introduction of daily error feedback was associated with a significant reduction in non-clinical prescribing errors.

Conclusion

The combined interventions of ZTP and daily error feedback were associated with a significant reduction in prescribing errors in the PICU, in line with Department of Health requirements of a 40 % reduction within 5 years.

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Abbreviations

ANOVA:

Analysis of variance

ARR:

Absolute risk reduction

CI:

Confidence interval

CPOE:

Computerised prescriber order entry

DoH:

Department of Health

ICU:

Intensive care unit

LCL:

Lower confidence limit

NHS:

National Health Service

NICU:

Neonatal intensive care unit

OBDs:

Occupied bed days

PICANet:

Paediatric Intensive Care Audit Network

PICU:

Paediatric intensive care unit

PIM2:

Paediatric index of mortality 2

rINN:

Recommended international non-proprietary name

RRR:

Relative risk reduction

UCL:

Upper confidence limit

UK:

United Kingdom

US:

United States

ZTP:

Zero tolerance prescribing

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Acknowledgments

Sincere thanks go to Ms Lynne Cochrane and Ms Venetia Horn for their constant support, Mr Duncan Shephard for his assistance with the statistical process control charts, Ms Gemma Ellis for her advice and encouragement and to Dr Allan Wardhaugh for the original concept of zero tolerance prescribing.

Author information

Authors and Affiliations

  1. Pharmacy Department, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK

    Rachelle Booth

  2. Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Trust, London, WC1N 3JH, UK

    Emma Sturgess, Alison Taberner-Stokes & Mark Peters

  3. Critical Care Group, Portex Unit, Institute of Child Health, University College London, London, UK

    Mark Peters

Authors
  1. Rachelle Booth
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  2. Emma Sturgess
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  3. Alison Taberner-Stokes
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  4. Mark Peters
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Corresponding author

Correspondence to Rachelle Booth.

Additional information

On behalf of the PICU/NICU Risk Action Group

Electronic supplementary material

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Supplementary material 1 (DOC 35 kb)

Supplementary material 2 (DOC 102 kb)

Appendix: Great Ormond St Hospital PICU/NICU Risk Action Group

Appendix: Great Ormond St Hospital PICU/NICU Risk Action Group

Mark Peters, MB ChB PhD MRCP FRCPCH

Rachelle Booth, BPharm MSc MRPharmS GPhC MPSNZ

Emma Sturgess, BSc RN

Alison Taberner-Stokes, RN

Andy Petros, MB BS MSc FRCP(UK) FRCPCH

Joe Brierley, MA MB ChB MRCP MRCPCH

Christine Pierce, MB BS BSc MRCP FRCPCH

Sanjiv Sharma, MBBS BSc MRCPCH

Paula Lister, MB BCh MRCPCH

Sophie Skellett, MA MB BChir MRCP FRCPCH

Quen Mok, MB BS DCH FRCP FRCPI FRCPCH

Darren Darby, RN MA

Kimberley Gray, RN Lead Nurse NICU

Ghislaine Stephenson, RN Lead Nurse PICU

Roisin Mulvaney, Patient Safety Manager

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Booth, R., Sturgess, E., Taberner-Stokes, A. et al. Zero tolerance prescribing: a strategy to reduce prescribing errors on the paediatric intensive care unit. Intensive Care Med 38, 1858–1867 (2012). https://doi.org/10.1007/s00134-012-2660-7

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  • DOI: https://doi.org/10.1007/s00134-012-2660-7

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