LAUSR

Aims We noted a pattern of multiple prescribing errors for cystic fibrosis (CF) inpatients, a high-risk group where polypharmacy is unavoidable. Errors persisted despite the introduction of electronic prescribing (EP) in our Children’s hospital in 2016, and a subsequent CF prescribing care set. EP is often seen by clinicians as a fixed unalterable system contributing to rather than ameliorating errors. We wanted to demonstrate increased use of the care set alongside an expected reduction in prescribing errors, through a process of multi-disciplinary quality improvement in liaison with EP programmers. Methods We met monthly, process mapping how the team interacts with our EP system. Sequential Plan-Do-Study-Act cycles were carried out and functionality added and optimised so they were used reliably, including care sets, automatic admission notification and judicious pop-up alerts. The National Coordinating Council for Medication Error Reporting and Prevention score (NCC MERP) was used to categorise error severity (A-I). Results In total, 20 patients (320 medication orders) were evaluated. The most common prescribing errors were: omission of a regular medicine (27%), wrong formulation (19%) and wrong dose (14%). One third of prescriptions with error(s) were non-CF specific drugs that could not be prescribed using the care set. These errors would require different error reduction strategies to be tested and were excluded from further analysis. Through our interventions, we demonstrated increased utilisation of the CF care set, from 42% to 70%, alongside a reduction in prescriptions with ≥1 error, from 43% to 27%. The highest severity category seen in this study (D: errors that required intervention to preclude harm, or extra monitoring) was reduced from 27% to 15%. Conclusion It is important to recognise that clinical teams can significantly reduce medication errors, and their severity, by working closely with EP programmers to change and adapt EP functions, and evaluate their subsequent utilisation and efficacy.