LAUSR

Prescribing and medication administration errors are common themes in Paediatrics. We observed an increasing trend of errors in our ward and assessment area. We undertook an audit to quantify errors within our department as per the EQUIP criteria suggested by the General medical council. A zero-tolerance approach was undertaken, and all errors from minor to severe were recorded. An alarming 90% of admissions within the audit period had minor to significant errors recorded in the initial audit. With the zero-tolerance approach, minor errors with no harm to life were also recorded. Previous research has suggested that good quality care depends upon different professions working together. We created a tripartite alliance involving nursing, pharmacy and medical teams. Our primary aim was to reduce medication prescription and administration errors by at least 10%. The small incremental change target was made in line with the quality improvement principles. We placed education at the heart of the change process, and the programme involved no costs apart from the time invested by the team. As a result, medication errors have been substantially reduced over the last five years, and education has been at the heart of the change process. The group has achieved change that is sustainable and prudent in design. We aligned staff, method and delivery to minimise avoidable harm and promoted co-production with patient involvement in educating staff about the impact of such errors. Working together as a team involving all three disciplines has helped us understand and modify practices that have led to an overall reduction in medication errors. We would like to share our change model that has influenced consistent and reliable results over several audit cycles.