P32 Rate of paediatric inpatient and discharge medication prescribing errors

2018 ◽  
Vol 103 (2) ◽  
pp. e1.37-e1
Author(s):  
Rahman Tasnim ◽  
Crook Joanne
Keyword(s):  
Patient Safety ◽  
Drug Interaction ◽  
Drug Dose ◽  
Electronic Prescribing ◽  
List Type ◽  
Prescribing Errors ◽  
Dose Frequency ◽  
Common Error ◽  
Feeding Tubes ◽  
Complex Patients

AimTo assess the documentation of allergies and quantify the rate of prescribing errors (PEs) for inpatient and discharge medications in paediatrics.MethodA data collection form was produced and data was collected prospectively by pharmacists for all paediatric patients’ prescribed inpatient and discharge medicines for 1 week during 9 am–5 pm. Electronic charts and allergy status for patients was checked, and all prescribed medicines were screened. If an error was identified, the drug name, type of error and category (wrong drug, dose, route, frequency, duplication etc.) were documented.Medications were screened against the British National Formulary for Children (BNFc), paediatric formularies and trust guidelines. Parenteral nutrition, IV fluids, outpatient and ambulatory medicines were excluded.ResultsData was collected for 152 patients with a total of 601 drugs screened. 151 patients (99%) had their allergies with nature of reaction documented as per the trust’s medicines policy. 89 PEs were identified (15% error rate). 89.9% of medicines were prescribed correctly in relation to the drug, dose, frequency, route and formulation. The most common error was wrong dose with 24 (27%) errors; 15 medicines (17%) were prescribed at doses too high. 7 errors occurred with high paracetamol dosing. This potentially occurred due to the dose banding in the BNFc which does not take into consideration dosing for small-for-age children.Wrong route (19 (21%) errors) was the 2nd common error identified. All of these errors related to administration of medicines via enteral feeding tubes. This highlights that careful consideration needs to be given when prescribing medicines for complex patients with feeding tubes.The incidence of drug interaction and contraindication PEs was low. This could be a result of electronic prescribing providing drug interaction alerts.ConclusionPEs can be defined as ‘an unintentional significant reduction in the probability of treatment being timely and effective or increase in the risk of harm when compared with generally accepted practice’.1PEs in the paediatric population can potentially have a serious impact on patient safety and lead to significant morbidity and mortality. In children, the risk of PEs is three times more likely to occur than in adults.1 One of the key improvements NHS England wants to achieve for 2017/2018 is reducing medication errors across the NHS.2 The trust paediatric clinical quality group have set an objective to have a 40% reduction in PEs by the end of 2017/2018.This audit demonstrates the most prevalent PEs which occurs at the trust and helps to identify the key actions that are needed to maintain patient safety. A paracetamol guideline will be introduced to highlight the difference between dosing-banding and weight-based dosing. Doctor’s training package will be updated to highlight common errors including the importance of thorough medicines reconciliation especially for complex patients with feeding tubes.ReferencesBannan DF, Tully MP. Bundle interventions used to reduce prescribing and administration errors in hospitalised children: A systematic review. Journal of Clinical Pharmacy and Therapeutics2016;41(3):246–255.NHS England. Next steps on the NHS five year forward view [Internet]Mar 2017. https://www.england.nhs.uk/wp-content/uploads/2017/03/NEXT-STEPS-ON-THE-NHS-FIVE-YEAR-FORWARD-VIEW.pdf [Accessed: 4th August 2017].

scholarly journals P029 Audit of aciclovir prescribing to assess whether changing the order of drop down box options in an electronic prescribing system can reduce prescribing errors

2019 ◽  
Vol 104 (7) ◽  
pp. e2.33-e2
Author(s):  
Clarissa Gunning ◽  
Jennifer Gray
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Improve Patient Safety ◽  
Error Rates ◽  
Electronic Prescribing ◽  
Contributory Factor ◽  
List Type ◽  
Prescribing Errors ◽  
Prescribing Error ◽  
Dosing Error

AimIn December 2016 it was identified that there had been multiple reports of prescribing errors with intravenous aciclovir on the paediatric intensive care unit (PICU). After investigation it was concluded that prescribers choosing incorrectly from a drop down menu of drug and dosing options on the electronic prescribing (EP) system was the main contributory factor. From 01/02/17 the aciclovir drop down options were prioritised, with the most frequently used option appearing first, to encourage prescribers to pick the correct regimen.MethodsThe trust has been using the Phillips ICCA EP system across all intensive care units since 2016. Picking errors when prescribing are known to be a potential risk within EP systems, however tailoring these systems to guide choice also has the potential to improve patient safety by reducing the risk of prescribing errors.1 Aciclovir has a complex range of dosing recommendations, especially in paediatrics, and incorrect prescribing increases the likelihood of subtherapeutic treatment or adverse effects. The aim of this audit is to assess whether changing the order of prescription choices on the drop down menu in the EP system reduced prescribing error rates for intravenous aciclovir. All prescriptions for aciclovir on PICU were identified during the 6 months before and after implementing the change, from 01/08/16 to 31/07/17. 65 prescriptions were included in the audit and were reviewed retrospectively using the EP system and electronic medical notes to assess whether the prescribed aciclovir dose and route was correct for the patient’s age, weight and indication as well as whether the appropriate drop down option had been selected by the prescriber. Dosing was assessed against recommendations in the British National Formulary for children and trust empirical antibiotic guidelines.ResultsDosing errors were found in 22% (14/65) of prescriptions overall during the review period. Before the change was implemented 26% (9/35) of aciclovir prescription doses were incorrect, reducing to 17% (5/30) after the change. The overall dosing error rate was 14% (7/50) in prescriptions where the correct drop down option was chosen, in comparison to 47% (7/15) in cases where the wrong option had been selected, suggesting the importance of choosing the correct pre-set option to minimise prescribing error rates. In cases where doses were incorrect, the prescriber had chosen the incorrect pre-set drop down option for the patient’s age and indication in 78% (7/9) of prescriptions before the order change compared to 0% (0/5) afterwards.ConclusionThese results suggest that prescribing error rates were reduced after making alterations to the order of prescription choices on the drop down menu in the EP system and that prioritising the order of these options may positively influence prescribing. Errors were not completely eliminated suggesting more work is required to further minimise risk.ReferenceAhmed Z, Garfield S, Jani Y, et al. Impact of electronic prescribing on patient safety in hospitals: implications for the UK. Pharm J 2016;8:1–11.

scholarly journals P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.49-e2
Author(s):  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Discharge Summary ◽  
Electronic Prescribing ◽  
List Type ◽  
Heparin Infusion ◽  
National Patient Safety Agency ◽  
High Dependency ◽  
National Patient ◽  
Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

scholarly journals P15 Using prescribing nudges to reduce medication errors: paracetamol on paediatric intensive care

2020 ◽  
Vol 105 (9) ◽  
pp. e13.2-e14
Author(s):  
Jenny Gray ◽  
Nicole Aubrey ◽  
Emma Hipkin ◽  
Nicholas Jones
Keyword(s):  
Medication Errors ◽  
Undergraduate Students ◽  
Reduction Rate ◽  
Traditional Education ◽  
Electronic Prescribing ◽  
List Type ◽  
Training Methods ◽  
Dose Frequency ◽  
Prescribing Quality ◽  
Intravenous Paracetamol

AimParacetamol is widely available and its safety profile is relatively good. However, the risk associated with a paracetamol overdose is much greater in a neonate than that associated with an adult.In 2018, 8% of paediatric medication errors related to the use of paracetamol, including three 10x overdoses. These irregular but serious risks are difficult to manage over time due to degradation of heightened awareness. The aim of this project was to improve the prescribing quality of IV paracetamol on PICU and prevent recurrence of a 10-fold overdose by the implementation of multi-level changes.MethodElectronic prescribing (EP) has been in use on our unit since 2016. Small changes (prescribing nudges) in the configuration of the EP system can be used to improve prescribing quality. Forced functions, automation and standardisation have been found to be more effective in this than more traditional education and training methods.1 2The changes implemented in January 2019 were as follows:Forced function: All paracetamol prescriptions for patients under 1 year of age were capped at 180 mg (change from 1000 mg). The prescriber could not enter a number greater than 180 mg.Automation: All oral paracetamol prescriptions were changed to automatically prescribe 15 mg/kg 6 hourly regardless of age (previously 2 different options requiring the prescriber to input dose and frequency according to formulary directions).Standardisation/simplification: All oral paracetamol prescriptions were rationalised to a single option with automatic dose and frequency as above (previously 2 different options unnecessarily).Reminder/rule: A rule of ‘Consultant Approval’ was added to all intravenous paracetamol prescriptions. The intention of this was for a review of the prescription before use to ensure appropriate use and dose/frequency. This could not be forced, so an education package was launched across the unit by the quality improvement group.Prescription details were downloaded from the EP system for 3 month periods pre and post changes. he data was audited by pharmacy undergraduate students for prescribing accuracy.ResultsThe forced function, automation and standardisation options were implemented with 100% compliance. The ‘consultant approval’ rule was followed in 23% of cases. Consultant review led to a 58.6% reduction of IV paracetamol prescriptions on the unit and zero prescriptions for the first 2 months post implementation. The usage of oral paracetamol increased accordingly. This change corresponded to an overall reduction rate of 41.7% for intravenous paracetamol prescriptions.ConclusionsThis project demonstrates how changes that increase automation within prescribing can reduce error and that implementation is more successful than education. A limitation of our data analysis was that we did not measure the effect on pain relief or pain scores in the patients who did not receive IV paracetamol compared to those who did.ReferencesCafazzo JA, et al. From discovery to design: the evolution of human factors in healthcare. Healthcare Quarterly 2012; 15: 24–29.Patel Ms, et al. Nudge units to improve the delivery of healthcare NEJM 2018; 378: 214–216.

scholarly journals P007 Improving paediatric chemotherapy prescribing through use of an electronic prescribing system

2019 ◽  
Vol 104 (7) ◽  
pp. e2.9-e2
Author(s):  
Charlotte Summerfield ◽  
Susan Kafka ◽  
Michelle Lewis ◽  
Guy Makin ◽  
Joseph Williams ◽  
...  
Keyword(s):  
Cancer Therapy ◽  
Malignant Disease ◽  
Electronic Prescribing ◽  
List Type ◽  
Prescribing Errors ◽  
Exact Test ◽  
Anti Cancer ◽  
Treatment Data ◽  
Cost Implications ◽  
Electronic Prescriptions

AimPaediatric prescriptions are almost 50% more likely to contain an error than adult orders. The risk of prescription error is further increased when prescribing for malignant disease.1 In 2017 the Trust introduced ChemoCare, an electronic prescribing system for paediatric chemotherapy. The primary aim of this study was to investigate whether implementing ChemoCare has affected the incidence and type of errors made in paediatric chemotherapy prescriptions, compared with written prescriptions. A secondary aim was to explore possible reasons why these prescribing errors may occur. Since 2014 it has been mandatory for all NHS England specialist trusts to send monthly submissions to the Systemic Anti-Cancer Therapy (SACT) Database, regarding the treatment of malignant disease in secondary care.2 Therefore, the study also analysed Trust compliance with communicating treatment data to SACT.MethodsData collection took place over a four-week period in Spring 2018. Prescriptions were reviewed by pharmacists and categorised as written or electronic. Prescriptions were then checked for 7 different error types; calculation error, drug prescribed on wrong day, incorrect drug prescribed for cycle, incorrect dose of concomitant medications, incorrect surface area used, not adjusted dose for previous age or weight related toxicities, no drug prescribed. The Fisher’s Exact test was employed to detect significance between chemotherapy prescription type and error incidence. A written questionnaire was designed to obtain the views of consultants, pharmacists and specialist trainees, and explore possible reasons why prescription errors occur. ChemoCare treatment data was retrospectively reviewed in order to determine how many prescribed cycles had been marked as ‘completed’.Results143 prescriptions were analysed. 34.4%(n=21) of written prescriptions contained errors, compared with 11.4% (n=5) of electronic orders. Two of the error types measured‘wrong calculation’ and ‘wrong drug prescribed for cycle’occurred significantly more frequently in written than electronic prescriptions.The Fisher’s Exact test produced p values of 0.017 and 0.008 respectively. Of the 409 treatment cycles prescribed and administered on the electronic system, 56.5% (n=231) had not been marked as ‘completed’, so would not be returned to SACT as administered chemotherapy. Failure to communicate accurate chemotherapy data to SACT not only limits research opportunities to progress safety aspects of delivering chemotherapy, but also has significant cost implications for the Trust, as chemotherapy treatment costs are not recovered.ConclusionThis study supports the use of an electronic prescribing system for ordering paediatric chemotherapy, given the significant reduction in errors compared with written prescriptions. The introduction of a chemotherapy-specific safe prescribing poster is suggested in order to improve compliance with ChemoCare. Further studies analysing national compliance with data return to SACT, are required to identify cost implications for the NHS and subsequent areas for quality improvement.ReferencesAvery AJ, Ghaleb M, Barber N, et al. Investigating the prevalence and causes of prescribing errors in general practice: The practice study. Pharmacoepidemiol Drug Saf 2012;21:4.NCRAS. Systemic Anti-Cancer Therapy Dataset [Internet]. [cited 2018 June 26]. Available from: http://www.ncin.org.uk/collecting_and_using_data/data_collection/chemotherapy

P10 To give, or not to give…

2018 ◽  
Vol 103 (2) ◽  
pp. e2.11-e2
Author(s):  
Zoe Lansdowne
Keyword(s):  
Patient Safety ◽  
Opioid Analgesics ◽  
Time Of Day ◽  
Electronic Prescribing ◽  
Time Range ◽  
List Type ◽  
University Hospitals ◽  
Policy Document ◽  
National Patient Safety Agency ◽  
National Patient

Aim‘Between September 2006 and June 2009, the NPSA (National Patient Safety Agency) received reports of 27 deaths, 68 severe harms and 21 383 other patient safety incidents relating to omitted or delayed medicines’.1 The Trust’s Medicines Code states that ‘critical’ medicines should be administered within one hour of the prescribed times, and all other medicines within 90 min.2 ‘Critical’ medicines relevant to NICU (Neonatal Intensive Care Unit) patients include injected antibiotics, anticoagulants, anticonvulsants, aminophylline infusions and strong opioid analgesics. The aim of this audit was to establish what proportion of medicines prescribed for patients on NICU were given outside of this policy.MethodData was downloaded for all NICU inpatients from the electronic prescribing system, ICCA, from 1/4/16 to 30/6/16 inclusive. It was then analysed using Excel. The data shows details of all regular drugs prescribed, the scheduled administration time and the time that the nurses recorded that the drug had been administered. Once only, when required and drug infusions longer than 4 hours were all excluded from this data capture. Scheduled doses of antibiotics that were intentionally delayed whilst awaiting levels, e.g. vancomycin and gentamicin, were excluded before data analysis.ResultsIt was found that over the 3 month period, 137 different patients were administered 10 642 regular doses of 51 different medications. 5.86% of these were classified as ‘delayed’ according to Trust policy. 97.6% of these delayed ‘critical’ medications were antibiotics, accounting for over 45% of the total delayed doses.Meropenem was found to be the antibiotic most frequently delayed, with over one quarter of all doses prescribed being administered more than 1 hour after the scheduled time. The delay in administration ranged from 65 mins to 6 hours. Ceftazidime was the next most frequently delayed, occurring 22.7% of the time, range 2.75 to 3.75 hours.The time of day when most drug delays occurred was between the times of 15:00 and 15:59, accounting for 8.2%. The percentage for each hourly time slot varied from 2.1% to 8.2%. Throughout the week, the percentage of delays on an individual day ranged from the most on Saturdays, 17.9%, to the least on Wednesdays, 9.6%.ConclusionsDelays in administering medicines can have significant detrimental effects for patient safety. Trust policy dictates that ‘critical’ medicines should be administered within 1 hour of the prescribed times.2 It can be seen from the results above that the administration of medications were delayed 5.86% of the time, with antibiotics accounting for over 45% of these delayed doses. The administration of meropenem was delayed over 25% of the time.ReferencesNational Patient Safety Agency. Rapid Response Report 009. Reducing harm from omitted and delayed medicines in hospital2010.Holmes, G. Chapter M09 policy for the administration of medicines [policy document]2016. University Hospitals Bristol NHS Foundation Trust.

P31 The effect of electronic prescribing on the incidence and nature of paediatric medication errors – an observational study

2018 ◽  
Vol 103 (2) ◽  
pp. e2.35-e2 ◽  
Author(s):  
Sattam Alenezi ◽  
Helen Sammons ◽  
Sharon Conroy
Keyword(s):  
Observational Study ◽  
General Medical Council ◽  
Clinical Work ◽  
Clinical Decision ◽  
Oral Route ◽  
Electronic Prescribing ◽  
Medical Council ◽  
List Type ◽  
Prescribing Errors ◽  
Significant Difference

BackgroundPrescribing errors may adversely affect the safety of patients of all ages and particularly paediatric patients due to the complexity of calculating individual patient doses and the common need to use medicines not designed for children.Electronic prescribing systems (EPS) are an intervention used to try reduce such errors. Few studies have evaluated their impact on prescribing errors in the UK particularly in neonatal/paediatric settings.AimsTo evaluate the nature and prevalence of prescribing errors in a UK children’s hospital which uses an EPS.To compare the results with those of a previous study1 conducted in the same hospital before the introduction of EPS.MethodsPharmacists were shadowed in their routine clinical work by the researcher who documented all prescribing errors identified. All electronic prescriptions checked for patients≤18 years in the paediatric wards were included in the data collection. Data was entered into a SPSS database for analysis.Types and severity of errors identified were categorised according to criteria used in a previous General Medical Council funded study (EQUIP).2Results were compared to a previous study from 2012/2013 in the same hospital (4204 prescriptions) using the same method before the introduction of EPS.ResultsObservation of 4035 prescriptions checked by pharmacists on their routine ward visits (754 patients) during September-December 2015 identified 208 prescribing errors, an error rate of 5.2% prescriptions.There was a statistically significant difference between the rate of errors identified in this study compared to that found in the written prescriptions (8.7%) in the previous study (p<0.001).Fifteen errors (7.2%) were classified as serious; 106 errors (51%) significant and minor errors represented the remaining errors (data unavailable for previous study).The most common types of error identified were omission of regular medications (1.7% total prescriptions vs 1.6% in previous study); under-doses (0.8% vs 0.7%), non-measurable doses (0.7% vs 1.5%) and overdoses (0.5% vs 0.7%). Illegible prescriptions were reduced from 2% total prescriptions in the first study to zero by the EPS. Errors involving incorrect/missing administration times were also reduced from 0.9% in the previous study to 0.2% in this study.Antibacterial, analgesics and bronchodilators were the most common groups of drugs associated with errors (28.8%, 10.6% and 10.6% of total errors respectively). The oral route was most commonly involved in errors (47.2% of total errors) followed by intravenous (30.3%) (data unavailable for previous study).ConclusionThe EPS was associated with a significant reduction in prescribing errors compared with written prescriptions. Illegible prescription errors were eliminated and incorrect/missing administration time errors greatly reduced. Errors involving non-measurable doses were more than halved. EPS however had a negligible effect on under- and over-dosing errors. Introduction of a more sophisticated clinical decision support system may help to reduce such errors.ReferenceConroy S, Alsenani A, Sammons H. An observational study of the role of the paediatric clinical pharmacist. Arch Dis Child2015;100(6):e1–e1.Dornan T, Ashcroft D, Heathfield H, et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP Study2009. http://www.gmc-uk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf [Accessed: 1 July 16.

SP3 The effect of electronic prescribing and medicines administration systems (epmass) on paediatric medication errors

2018 ◽  
Vol 103 (2) ◽  
pp. e1.23-e1
Author(s):  
Aragon Octavio ◽  
Fayyaz Goher ◽  
Gill Andrea ◽  
Morecroft Charles
Keyword(s):  
Medication Errors ◽  
Error Rate ◽  
Error Rates ◽  
Electronic Prescribing ◽  
Prescribing Errors ◽  
Error Type ◽  
Common Error ◽  
Period 2 ◽  
The Difference ◽  
Paediatric Prescribing

BackgroundThe complex nature of paediatric prescribing makes this population more vulnerable to medication errors.1Electronic Prescribing and Medicines Administration Systems (EPMASs) have been suggested to improve paediatric medication safety by reducing prescribing errors.AimTo identify and compare the number and nature of paediatric medication errors pre and post introduction of an EPMAS at a tertiary paediatric hospital.MethodologyPharmacists collected data monthly on the number of new items prescribed and the number of errors (if any) detected in these prescriptions following methodology from the EQUIP study.2 The EPMAS Meditechv6 was introduced in June 2015. Data analysed included forms from 1st-January-2015 to 30th-June-2015 (period 1: pre-EPMAS) and 1st-January-2016 to 30th-June-2016 (period 2: post-EPMAS). The analysis aimed to investigate the rate, type and severity of errors as well as the prescriber grade, prescribing stage and drug class associated with each. Descriptive statistical methods were used to analyse the frequency and nature of errors pre and post implementation of Meditech. Statistical significance was tested using a contingency Chi-squared (χ2) test for the difference in error rates across both periods and a Mann-Whitney test for the difference between the severities of errors across both periodsResultsAn increase of 6.4% in error rate was detected post-Meditech introduction with 67 errors in 1706 items (3.9%) during period 1 and 151 errors in 1459 items (10.3%) during period 2 (p<0.001, χ2 test). FY2 doctors and ‘admission stage’ were associated with the highest error rates across both periods. Minor severity errors were the most common in both periods, with 55.2% in period 1% and 66.2% in period 2. No statistical difference was detected (p=0.403) in the severity of errors reported although the proportion of significant and serious errors decreased from 38.8% to 27.8% and 6.0% to 0.7% respectively. No errors were classed to be potentially lethal in period 1, however there was one such incident in period 2. Underdosing was the most common error type in period 1 (22.4%), falling to 4.0% in period 2. Omission on admission was the most common error type in period 2, with an error rate of 37.7% vs 20.9% in period 1. Antibacterials and analgesics were the most common classes of drugs involved in errors in both periods, although a wider range of drug classes were involved in errors post Meditech introductionConclusionA significant increase of 6.4% in error rate was found post implementation of Meditech highlighting the concept of EPMAS-facilitated errors. The positive effect of EPMASs is also apparent as the incidence of significant and serious errors decreased in period 2, although this difference was not statistically significant. Reaching definitive conclusions is difficult due to the lack of available research into the effects of EPMASs on paediatric prescribing and due to methodological limitations. However, it can be suggested that introducing functions such as comprehensive decision support and dose calculators may overcome the shortcomings of the current system3 and allow for the true benefits of EPMASs in improving paediatric medication safety to be demonstrated.ReferencesNational Patient Safety Agency. Review of patient safety for children and young people 2009. England: National Reporting and Learning Services. http://www.nrls.npsa.nhs.uk/resources/?entryid45=5986 [Accessed: 29th October 2016].Dornan T, et al. An in-depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education: EQUIP study. Final Report to the General Medical Council 2009. http://www.gmcuk.org/FINAL_Report_prevalence_and_causes_of_prescribing_errors.pdf_28935150.pdf [Accessed: 9th November 2016].Johnson KB, Lehmann CU. Electronic prescribing in paediatrics: Toward safer and more effective medication management. Paediatrics 2013;131(4):e1350–e1356. doi:10.1542/peds.2013-0193

Comparative prevalence of prescription errors in randomly collected samples from hospital pharmacy and community pharmacy, Punjab, Pakistan

2017 ◽  
Vol 3 (3) ◽  
pp. 350-353
Author(s):  
Sabeeha Kausar ◽  
Muhammad Imran
Keyword(s):  
Patient Safety ◽  
Community Pharmacy ◽  
Hospital Pharmacy ◽  
Dosage Form ◽  
Physician Education ◽  
Prescribing Errors ◽  
Prescribing Practices ◽  
Prescription Errors ◽  
Dosing Frequency ◽  
N 93

Objective: This study was conducted to analyze and evaluate the prevalence of prescription errors, to optimize the medication effectiveness and patient safety and to encourage the rational prescribing practices. Method: sample of 250 prescriptions was randomly collected from outdoor hospital pharmacy (n=157) and from community pharmacy (n=93) and analyzed manually to estimate the prevalence of prescription errors. Results: Results calculated by using SPPS Version 23 and MS Excel 2013 are as follow; 41.4% prescription collected from outdoor hospital pharmacy presented significant prescribing errors while 54.7% in sample collected from community pharmacy. The prescriptions were segregated and errors were estimated using following parameters; dose, dosage form, dosing frequency, drug-drug interactions, spelling, and duplication of generic, therapy duration and unnecessary drugs. Conclusion: The prevalence of prescribing errors in sample of community pharmacy was 12.37% greater than found in prescriptions of hospital pharmacy. The prevalence of prescription errors can be reduced by physician education, using automated prescribing systems and immediate review of prescription by pharmacist before dispensing of prescription items to patients.

scholarly journals Prescribing Errors With Direct Oral Anticoagulants and Their Impact on the Risk of Bleeding in Patients With Atrial Fibrillation

2021 ◽  
pp. 107424842110196
Author(s):  
Bruria Hirsh Raccah, PharmD, PhD ◽  
Yevgeni Erlichman ◽  
Arthur Pollak ◽  
Ilan Matok ◽  
Mordechai Muszkat
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Negative Impact ◽  
Conditional Logistic Regression ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Drug Dose ◽  
Prescribing Errors ◽  
Duration Of Treatment ◽  
Inappropriate Treatment

Introduction: Anticoagulants are associated with significant harm when used in error, but there are limited data on potential harm of inappropriate treatment with direct oral anticoagulants (DOACs). We conducted a matched case-control study among atrial fibrillation (AF) patients admitting the hospital with a chronic treatment with DOACs, in order to assess factors associated with the risk of major bleeding. Methods: Patient data were documented using hospital’s computerized provider order entry system. Patients identified with major bleeding were defined as cases and were matched with controls based on the duration of treatment with DOACs and number of chronic medications. Appropriateness of prescribing was assessed based on the relevant clinical guidelines. Conditional logistic regression was used to evaluate the potential impact of safety-relevant prescribing errors with DOACs on major bleeding. Results: A total number of 509 eligible admissions were detected during the study period, including 64 cases of major bleeding and 445 controls. The prevalence of prescribing errors with DOACs was 33%. Most prevalent prescribing errors with DOACs were “drug dose too low” (16%) and “non-recommended combination of drugs” (11%). Safety-relevant prescribing errors with DOACs were associated with major bleeding [adjusted odds ratio (aOR) 2.17, 95% confidence interval (CI) 1.14-4.12]. Conclusion: Prescribers should be aware of the potential negative impact of prescribing errors with DOACs and understand the importance of proper prescribing and regular follow-up.

scholarly journals Analysis of medication therapy discontinuation orders in new electronic prescriptions and opportunities for implementing CancelRx

2018 ◽  
Vol 25 (11) ◽  
pp. 1516-1523 ◽  
Author(s):  
Yuze Yang ◽  
Stacy Ward-Charlerie ◽  
Nitu Kashyap ◽  
Richelle DeMayo ◽  
Thomas Agresta ◽  
...  
Keyword(s):  
Patient Safety ◽  
Alternative Therapy ◽  
Electronic Prescribing ◽  
Electronic Prescription ◽  
User Training ◽  
Medication Therapy ◽  
Search Terms ◽  
Medication Discontinuation ◽  
Representative Random Sample ◽  
Nationally Representative

Abstract Objective To illustrate the need for wider implementation of the CancelRx message by quantifying and characterizing the inappropriate usage of new electronic prescription (NewRx) messages for communicating discontinuation instructions to pharmacies. Materials and Methods A retrospective analysis on a nationally representative random sample of 1 400 000 NewRx messages transmitted over 7 days to identify e-prescriptions containing medication discontinuation instructions in NewRx text fields. A vocabulary of search terms signifying cancellation instructions was formulated and then iteratively refined. True-positives were subsequently identified programmatically and through manual reviews. Two independent reviewers identified incidences in which these instructions were associated with high-alert or look-alike-sound-like (LASA) medications. Results We identified 9735 (0.7% of the total) NewRx messages containing prescription cancellation instructions with 78.5% observed in the Notes field; 35.3% of identified NewRxs were associated with high-alert or LASA medications. The most prevalent cancellation instruction types were medication strength or dosage changes (39.3%) and alternative therapy replacement orders (39.0%). Discussion While the incidence of prescribers using the NewRx to transmit cancellation instructions was low, their transmission in NewRx fields not intended to accommodate such information can produce significant potential patient safety concerns, such as duplicate or inaccurate therapies. These findings reveal the need for wider industry adoption of the CancelRx message by electronic health record (EHR) and pharmacy systems, along with clearer guidance and improved end-user training, particularly as states increasingly mandate electronic prescribing of controlled substances. Conclusion Encouraging the use of CancelRx and reducing the misuse of NewRx fields would reduce workflow disruptions and unnecessary risks to patient safety.

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