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. 2013 Mar;22(3):256-62.
doi: 10.1136/bmjqs-2012-001089. Epub 2012 Oct 4.

Personalised performance feedback reduces narcotic prescription errors in a NICU

Kevin M Sullivan  1 , Sanghee Suh, Heather Monk, John Chuo
Affiliations
Free PMC article

Personalised performance feedback reduces narcotic prescription errors in a NICU

Kevin M Sullivan et al. BMJ Qual Saf. 2013 Mar.
Free PMC article

Abstract

Objective: Neonates are at high risk for significant morbidity and mortality from medication prescribing errors. Despite general awareness of these risks, mistakes continue to happen. Alerts in computerised physician order entry intended to help prescribers avoid errors have not been effective enough. This improvement project delivered feedback of prescribing errors to prescribers in the neonatal intensive care unit (NICU), and measured the impact on medication error frequency.

Methods: A front-line multidisciplinary team doing multiple Plan Do Study Act cycles developed a system to communicate prescribing errors directly to providers every 2 weeks in the NICU. The primary outcome measure was number of days between medication prescribing errors with particular focus on antibiotic and narcotic errors.

Results: A T-control chart showed that the number of days between narcotic prescribing errors rose from 3.94 to 22.63 days after the intervention, an 83% improvement. No effect in the number of days between antibiotic prescribing errors during the same period was found.

Conclusions: An effective system to communicate mistakes can reduce some types of prescribing errors.

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Figures

Figure 1
Figure 1
Three critical project drivers and their related Plan Do Study Act cycles.
Figure 2
Figure 2
Prescriber feedback workflow process (A) prescriber enters order, (B) pharmacist reviews and discovers error, (C) team reviews error database every 2 weeks, (D) feedback messages created and sent to prescriber, (E) prescriber receives, reads and may respond to the feedback, (F) team reviews and uses feedback to improve system.
Figure 3
Figure 3
Days between pharmacy-intercepted narcotic prescribing errors. Feedback program implemented 3 January 2010 in the setting of other initiatives (hospital safety behaviour training, and verbalise medication units completely during rounds).
Figure 4
Figure 4
Days between pharmacy-intercepted antibiotic prescribing errors Feedback program implemented 3 January 2010 in the setting of other initiatives.
See this image and copyright information in PMC

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