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 The Impact of Technology on Prescribing Errors in Pediatric Intensive Care: A Before and After Study

2020 ◽  
Vol 11 (02) ◽  
pp. 323-335 ◽  
Author(s):  
Moninne M. Howlett ◽  
Eileen Butler ◽  
Karen M. Lavelle ◽  
Brian J. Cleary ◽  
Cormac V. Breatnach
Keyword(s):  
Intensive Care ◽  
New Technology ◽  
Tertiary Care ◽  
Pediatric Intensive Care ◽  
Error Rates ◽  
Electronic Prescribing ◽  
Prescribing Errors ◽  
Before And After ◽  
The Impact ◽  
Before And After Study

Abstract Background Increased use of health information technology (HIT) has been advocated as a medication error reduction strategy. Evidence of its benefits in the pediatric setting remains limited. In 2012, electronic prescribing (ICCA, Philips, United Kingdom) and standard concentration infusions (SCIs)—facilitated by smart-pump technology—were introduced into the pediatric intensive care unit (PICU) of an Irish tertiary-care pediatric hospital. Objective The aim of this study is to assess the impact of the new technology on the rate and severity of PICU prescribing errors and identify technology-generated errors. Methods A retrospective, before and after study design, was employed. Medication orders were reviewed over 24 weeks distributed across four time periods: preimplementation (Epoch 1); postimplementation of SCIs (Epoch 2); immediate postimplementation of electronic prescribing (Epoch 3); and 1 year postimplementation (Epoch 4). Only orders reviewed by a clinical pharmacist were included. Prespecified definitions, multidisciplinary consensus and validated grading methods were utilized. Results A total of 3,356 medication orders for 288 patients were included. Overall error rates were similar in Epoch 1 and 4 (10.2 vs. 9.8%; p = 0.8), but error types differed (p < 0.001). Incomplete and wrong unit errors were eradicated; duplicate orders increased. Dosing errors remained most common. A total of 27% of postimplementation errors were technology-generated. Implementation of SCIs alone was associated with significant reductions in infusion-related prescribing errors (29.0% [Epoch 1] to 14.6% [Epoch 2]; p < 0.001). Further reductions (8.4% [Epoch 4]) were identified after implementation of electronically generated infusion orders. Non-infusion error severity was unchanged (p = 0.13); fewer infusion errors reached the patient (p < 0.01). No errors causing harm were identified. Conclusion The limitations of electronic prescribing in reducing overall prescribing errors in PICU have been demonstrated. The replacement of weight-based infusions with SCIs was associated with significant reductions in infusion prescribing errors. Technology-generated errors were common, highlighting the need for on-going research on HIT implementation in pediatric settings.

P30 The effects of introducing electronic prescribing for paediatric chemotherapy using aria on prescribing error rates at a primary treatment centre

2018 ◽  
Vol 103 (2) ◽  
pp. e2.33-e2
Author(s):  
Peter Cook ◽  
Andy Fox
Keyword(s):  
Acute Lymphoblastic Leukaemia ◽  
Error Rate ◽  
Lymphoblastic Leukaemia ◽  
Error Rates ◽  
Electronic Prescribing ◽  
Patient Specific ◽  
Prescribing Errors ◽  
Prescribing Error ◽  
Error Type ◽  
Before And After

IntroductionPrescribing of medication in children is a very complex process that involves an understanding of paediatric physiology, disease states, medication used and pharmacokinetics as well as patient specific details, their co-morbidities and their clinical condition. The most common medication errors have been identified as dosing, route of administration, and frequency of administration. Computerised provider order entry has been shown to reduce the number of prescribing errors related to chemotherapy as well as the likelihood of dose and calculation errors in paediatric chemotherapy prescribing. Locally, paediatric chemotherapy is prescribed on pre-printed paper prescriptions. Adaptation and implementation of ARIA electronic prescribing (EP) system for use in paediatric chemotherapy was undertaken by a Specialist Paediatric Oncology Pharmacist and was rolled out for use in January 2016 for patients with acute lymphoblastic leukaemia.MethodThe United Kingdom National Randomised Trial for Children and Young Adults with Acute Lymphoblastic Leukaemia and Lymphoma 2011 (UKALL, 2011) was developed for use on EP, with prescribing of all other chemotherapy remaining on paper. The number and type of prescribing errors were collected during a pre-implementation phase from January 2015 to June 2015. After the introduction of EP and following a 2 month acclimatisation period, a second period of data collection took place between March 2016 and July 2016. Overall prescribing error rates and the frequency of each error type were calculated both before and after implementation.ResultsBefore the introduction of EP for paediatric chemotherapy, the overall error rate was 18.4% with a total of 16 different errors seen. Post implementation, overall error rate increased to 25.7% (p<0.001) with a total of 10 different errors seen. After introduction of EP, prescribing error rates on paper were 30.6% and on EP were 7.0% (p<0.001). Only 5 different error types were seen with electronic prescribing. The most commonly seen errors in prescribing with paper, both before and after were almost eliminated with the introduction of EP.ConclusionThe introduction of EP has resulted in a significant reduction in prescribing error rates compared to paper based prescribing for paediatric chemotherapy. Overall the prescribing error rate increased after the introduction of EP but this was related to an increased rate on the paper prescriptions. One possible reason for this was the use of dual systems for prescribing. In addition there was unforeseen relocation and building work within the paediatric cancer unit, which affected prescribing time allocation. There were also several staff shortages within the prescribing team after implementation and this resulted in an increased workload on the remaining chemotherapy prescribers. All these issues could have attributed to the increase in error rates. The most common errors seen with chemotherapy prescribing have been reduced with EP as protocols have been developed with a focus on prescribing safety. Further work is needed as more prescribing takes place on EP to assess the full impact it has on paediatric chemotherapy error rates.

scholarly journals P19 Direct observational study of infusion errors associated with smart-pump technology in paediatric intensive care

2020 ◽  
Vol 105 (9) ◽  
pp. e15.2-e16
Author(s):  
Moninne Howlett ◽  
Erika Brereton ◽  
Cormac Breatnach ◽  
Brian Cleary
Keyword(s):  
Intensive Care ◽  
Intensive Care Units ◽  
The United States ◽  
Error Rates ◽  
Paediatric Intensive Care ◽  
Electronic Prescribing ◽  
List Type ◽  
Paediatric Hospital ◽  
Smart Pumps ◽  
Smart Pump

AimsProcesses for delivery of high-risk infusions in paediatric intensive care units (PICUs) are complex. Standard concentration infusions (SCIs), smart-pumps and electronic prescribing are recommended medication error reduction strategies.1 2 Implementation rates are low in Irish and UK hospitals.2 3 Since 2012, the PICU of an Irish tertiary paediatric hospital has been using a smart-pump SCI library, interfaced with electronic infusion orders (Philips ICCA®). The incidence of infusion errors is unknown. This study aims to determine the frequency, severity and distribution of smart-pump infusion errors and to identify contributory factors to the occurrence of infusion errors.MethodsProgrammed infusions are directly observed at the bedside. Parameters are compared against medication orders and auto-populated infusion data. Identified deviations are categorised as either medication errors or discrepancies. Five opportunities for error (OEs) were identified: programming, administration, documentation, assignment, data transfer. Error rates (%) are calculated as: infusions with errors; and errors per OE. Pre-defined definitions, multi-disciplinary consensus and grading processes are employed.ResultsA total of 1023 infusions for 175 patients were directly observed on 27 days between February and September 2017. 74% of patients were under 1 year, 32% under 1 month. The drug-library accommodated 96.5% of all infusions. Compliance with the drug-library was 98.9%. 55 infusions had ≥ 1 error (5.4%); a further 67 (6.3%) had ≥ 1 discrepancy. From a total of 4997 OEs, 72 errors (1.4%) and 107 discrepancies (2.1%) were observed. Documentation errors were most common; programming errors were rare (0.32% OE). Errors are minor, with just one requiring minimal intervention to prevent harm.ConclusionThis study has highlighted the benefits of smart-pumps and auto-populated infusion data in the PICU setting. Identified error rates are low compared to similar studies.4 The findings will contribute to the limited existing knowledge base on impact of these interventions on paediatric infusion administration errors.ReferencesInstitute for Safe Medication Practices, ISMP. 2018–2019 Targeted medication safety best practices for hospitals2018 [Available from: http://www.ismp.org/tools/bestpractices/TMSBP-for-Hospitalsv2.pdf [Accessed: June 2019]Oskarsdottir T, Harris D, Sutherland A, et al. A national scoping survey of standard infusions in paediatric and neonatal intensive care units in the United Kingdom. J Pharm Pharmacol 2018;70:1324–1331.Howlett M, Curtin M, Doherty D, Gleeson P, Sheerin M, Breatnach C. Paediatric standardised concentration infusions – A national solution. Arch Dis Child. 2016;101:e2.Blandford A, Dykes PC, Franklin BD, et al. Intravenous Infusion Administration: A comparative study of practices and errors between the United States and England and their Implications for patient safety. Drug Saf. 2019;42:1157–1165

scholarly journals P033 Improving paediatric practice through multidisciplinary safety huddles

2019 ◽  
Vol 104 (7) ◽  
pp. e2.38-e2
Author(s):  
Ka Yu Yung ◽  
Ruchi Sinha ◽  
Susan Giles
Keyword(s):  
Patient Safety ◽  
Improve Patient Safety ◽  
Hospital Setting ◽  
Error Rates ◽  
Lessons Learned ◽  
List Type ◽  
Department Of Health ◽  
Health And Social Care ◽  
The Individual ◽  
Learned Safety

BackgroundMedication is the most prevalent therapeutic intervention in patient management.1 Medication errors are incidents that have occurred in the medication cycle of prescribing, dispensing, administering, monitoring, or providing medicines advice, regardless of whether they caused harm.1 In a hospital setting, medication error rates are similar amongst adults and children but there is three times the potential to cause harm in the latter. Due to the complexities that are associated with prescribing for children and the potential for the lack of necessary metabolic reserves to buffer any consequences,2 ensuring high quality prescribing in paediatrics is paramount and this requires multidisciplinary team (MDT) collaboration. Pharmacy contributions: The introduction of weekly Safety Huddles was started on the Paediatric Intensive Care Unit (PICU) in March 2017 – led by the PICU consultant, paediatric risk nurse and pharmacist. Safety Huddles are short MDT briefings, involving the ward-based medical, nursing & pharmacy teams, providing a platform for all staff to understand things that are happening within the ward and anticipate further risks to improve patient safety and care. The aim is to create an open environment where staff regularly communicate and feel safe to raise concerns about patient safety. The Safety Huddle comprises of three main aspects: pharmacy updates as ‘top tips’; Datix incident reports and issues/concerns of the week. Pharmacy interventions are collected on a daily basis and fed back to the individual prescriber immediately where possible as the exchange of information must be rapid to optimise engagement. These then form the weekly ‘top tips’ which are shared with the whole MDT, along with Datix reports and any particular concerns where learning and action points are developed and agreed through contribution by all.OutcomeThe concept of Safety Huddles has been adapted and fully established throughout all paediatric and neonatal specialities at the Trust. There has been an increase in the number of incidents reported since the implementation of the Safety Huddles. Error themes and their impact are looked at so the team learn from improvement and harm occurrence or near misses. The measurement of interventions provides a weekly update to the individual team to see if these are being carried out effectively and to improve where necessary. It allows identification of triggers and incorporates problem solving through the involvement of all members of the team, improving staff, patient and family experience and communication in addition to reducing harm, allowing Trust values to be met. Lessons learned: Safety Huddles are held in the spirit of learning and improvement. It allows integration with the wider team, empowering the team to work unanimously towards the ultimate goal of delivering the best patient care.ReferencesDepartment of Health and Social Care. The Report of the Short Life Working Group on reducing medication- related harm. February 2018.Department of Health. Medicines Standard: National Service Framework for Children, Young People and Maternity Services. October 2004. Department of Health. Building a Safer NHS or Patients: Improving Medication Safety. January 2004.

scholarly journals 1 Developing consensus on hospital prescribing indicators of potential harm for infants and children

2018 ◽  
Vol 103 (2) ◽  
pp. e2.1-e2
Author(s):  
Andy Fox
Keyword(s):  
Expert Panel ◽  
Clinical Decision ◽  
Error Rates ◽  
Electronic Prescribing ◽  
Prescribing Errors ◽  
Prescribing Error ◽  
Prescribing Indicators ◽  
Potential Harm ◽  
The Uk ◽  
Paediatric Prescribing

AimsTo develop a list of hospital based paediatric prescribing indicators that can be used to assess the impact of electronic prescribing or clinical decision support tools on paediatric prescribing errors.BackgroundMedication errors are a major cause for concern in the NHS. Prescribing is part of the medication use process and is a complex task requiring an understanding of medicines, disease processes, and patient parameters. Systematic reviews have reported that medication errors occur in as many as 50% of hospital admissions and prescribing error rates in the UK hospitals vary between 9% and 15%.Prescribing for children is further complicated by the need to take into account weight, altered physiology and pharmacokinetics. Prescribing error rates of 13.1% have been reported in children with a potentially greater impact due to the nature of the patients.Electronic prescribing (EP) while relatively uncommon in UK hospitals is an important tool in reducing prescribing errors. EP systems have been shown to have a positive impact on prescribing errors, however methodologies vary and the reduction in harm is rarely investigated. A standard tool to allow an evaluation of the harm reduction is desirable and currently does not exist for the paediatric setting.MethodsTwo rounds of an electronic consensus method (eDelphi) were carried out with 21 expert panellists from the UK. Panellists were asked to score each prescribing indicator for its likelihood of occurrence and severity of outcome should the error occur. The scores were combined to produce a risk score and a median score for each indicator calculated. The degree of consensus between panellists was defined as the proportion that gave a risk score in the same category as the median. Indicators were included if a consensus of 80% or higher was achieved and were in the high risk categories.ResultsAn expert panel consisting of 8 pharmacists and 13 paediatricians with a total of 437 years of clinical experience completed an exploratory round and two rounds of scoring. This identified 41 paediatric prescribing indicators with a high risk rating and greater than 80% consensus. The most common error type within the indicators was wrong dose (n=19) and the most common drug classes were antimicrobials (n=10) and cardiovascular (n=7).ConclusionsA set of 41 paediatric prescribing indicators describing potential harm for the hospital setting have been identified by an expert panel. The indicators provide a standardised method of evaluation of prescribing data on both paper and electronic systems. They can also be used to assess implementation of clinical decision support systems or other quality improvement initiatives.

ASSESSING THE IMPACT OF A NEWLY INTRODUCED ELECTRONIC PRESCRIBING SYSTEM ACROSS A PAEDIATRIC DEPARTMENT – LESSONS LEARNED

2016 ◽  
Vol 101 (9) ◽  
pp. e2.13-e2 ◽  
Author(s):  
Anastasia Tsyben ◽  
Nigel Gooding ◽  
Wilf Kelsall
Keyword(s):  
Good Practice ◽  
Electronic System ◽  
Daily Basis ◽  
Error Rates ◽  
Lessons Learned ◽  
Electronic Prescribing ◽  
Prescribing Errors ◽  
Prescribing Error ◽  
New Challenges ◽  
The Impact

AimPrescribing audits have shown that the Women's and Children's Directorate reported higher number of prescription errors on the paediatric and neonatal wards compared to other areas in the Trust. Over the last three years a multidisciplinary prescribing team (PT), which included senior clinicians, pharmacists and trainees introduced a number of initiatives to improve the quality of prescribing. Strategies included structured departmental inductions, setting up of designated prescribing areas and reviewing errors with the prescriber. Year on year there were fewer prescribing errors.1 With the introduction of a new electronic prescribing system in October 2014 prescribing error rates were expected to decrease further, eradicating omissions around allergy recording, ward location and drug names. The aim of this abstract is to highlight the impact of the new system and describe lessons learned.MethodIn the summer of 2014, all inpatient drug charts across the department were reviewed on three non-consecutive days over a period of three weeks. Prescribing errors were identified by the ward pharmacist. Errors were grouped according to type and further analyzed by the PT. Errors deemed to have no clinical significance were excluded. Error rates were compared to the previous audits performed with identical methodology. Following the introduction of the electronic prescribing system, the ward pharmacists continued to review prescription charts on daily basis and generate regular error reports to notify the staff of new challenges.ResultsThere were 174 (14%) errors out of 1225 prescriptions on 181 drug charts. The most commonly made mistakes included drug name errors, strength of preparation, allergies and ward documentation, prescriber's signature omissions, and antibiotic review and end dates. The introduction of an electronic system has eliminated drug name, strength of preparation, allergy recording and ward errors. However, serious challenges have been identified: entering of an incorrect weight resulted in all drug dosages being inaccurate; the timing of drug levels for Vancomycin and Gentamicin and the administration of subsequent doses have been problematic. Communication difficulties between all staff groups has led to dosage omission, duplicate administration and confusion around start and stop dates. The ability to prescribe away from the bedside and indeed the ward has compounded some of these problems.ConclusionThe implementation of a new electronic system has reduced prescribing errors but has also resulted in new challenges, some with significant patient safety implications. The lessons learned and good practice introduced following previous audits of “traditional paper based” prescribing are equally important with electronic prescribing. Communication between staff groups is crucial. It is likely that the full benefits of the system will be realized a year after its introduction. On-going audit is required to assess the impact and safety of the electronic prescribing and lessons learned.

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 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.

Atmung – Standardisierte Checkliste macht Intubation von Neugeborenen sicherer

2017 ◽  
Vol 22 (03) ◽  
pp. 124-125
Author(s):  
Maria Weiß
Keyword(s):  
Intensive Care Unit ◽  
Patient Safety ◽  
Intensive Care ◽  
Neonatal Intensive Care Unit ◽  
Neonatal Intensive Care ◽  
Improve Patient Safety ◽  
Improve Patient

Hatch LD. et al. Intervention To Improve Patient Safety During Intubation in the Neonatal Intensive Care Unit. Pediatrics 2016; 138: e20160069 Kinder auf der Neugeborenen-Intensivstation sind besonders durch Komplikationen während des Krankenhausaufenthaltes gefährdet. Dies gilt auch für die Intubation, die relativ häufig mit unerwünschten Ereignissen einhergeht. US-amerikanische Neonatologen haben jetzt untersucht, durch welche Maßnahmen sich die Komplikationsrate bei Intubationen in ihrem Perinatal- Zentrum senken lässt.

scholarly journals Assessment of patient safety culture in intensive care units and factors affecting it

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M A Tlili ◽  
W Aouicha ◽  
H Lamine ◽  
E Taghouti ◽  
M B e n Dhiab ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intensive Care ◽  
Adverse Events ◽  
Intensive Care Units ◽  
Safety Culture ◽  
Improve Patient Safety ◽  
Healthcare Quality ◽  
Patient Safety Culture ◽  
Cross Sectional ◽  
Learning From Errors

Abstract Background The intensive care units are a high-risk environments for the occurrence of adverse events with serious consequences. The development of patient safety culture is a strategic focus to prevent these adverse events and improve patient safety and healthcare quality. This study aimed to assess patient safety culture in Tunisian intensive care units and to determine its associated factors. Methods It is a multicenter, descriptive cross-sectional study, among healthcare professionals of the intensive care units in the Tunisian center. The data collection was spread over a period of 2 months (October-November 2017). The measuring instrument used is the validated French version of the Hospital Survey On Patient Safety Culture questionnaire. Data entry and analysis was carried out by the Statistical Package for Social Sciences (SPSS 20.0) and Epi Info 6.04. Chi-square test was used to explore factors associated with patient safety culture. Results A total of 404 professionals participated in the study with a participation rate of 81.94%, spread over 10 hospitals and 18 units. All dimensions were to be improved. The overall perception of safety was 32.35%. The most developed dimension was teamwork within units with a score of 47.87% and the least developed dimension was the non-punitive response to error (18.6%). The patient safety culture was significantly more developed in private hospitals in seven of the 10 dimensions. Participants working in small units had a significantly higher patient safety culture. It has been shown that when workload is reduced the patient safety culture was significantly increased. Conclusions This study has shown that the patient safety culture still needs to be improved and allowed a clearer view of the safety aspects requiring special attention. Thus, improving patient safety culture. by implementing the quality management and error reporting systems could contribute to enhance the quality of healthcare provided to patients. Key messages The culture of culpability is the main weakness in the study. Encouraging event reporting and learning from errors s should be priorities in hospitals to enhance patient safety and healthcare quality.

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