Prescribing Errors in Paediatrics Andrea Gill Clinical Pharmacy Services Manager Alder Hey Children’s NHS Foundation Trust, Liverpool, UK

Prescribing Errors in Paediatrics Prevalence 3-37% items prescribed Most common paediatric incident type reported to NPSA Error Types dosing errors most common (23% NPSA) Incomplete prescriptions

An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education - EQUIP study Systematic review Prevalence study Qualitative investigation Recommendations

An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education - EQUIP study 19 Acute Hospitals in North West England 7 data collection days Standardised data collection forms Validated definitions Prescribing errors Severity ratings

EQUIP Study EQUIP 2008 Prevalence 124,260 newly prescribed items 11,077 errors detected Mean error rate 8.9% Grade of prescriber FY1 8.4% error rate FY2 10.3% error rate Severity of error Potentially lethal 1.7% Serious 5.6% Significant 53% In 2008 the GMC commissioned Manchester University to undertake a study of prescribing errors specifically looking at whether the changes to the undergraduate medical curriculum were equipping specifically FY1 doctors for the prescribing roles they needed to undertake in practice. 19 of the North West hospitals took part including ourselves, Royal, Aintree and LHCH and the data was pooled (and interestingly found that FY1 doctors were better than average with FY2 doctors being the most likely candidates for making prescribing errors!) Dornan et al, General Medical Council report, Dec 2009

Prescribing errors at Alder Hey Monthly data collection using EQUIP forms All errors scrutinised by senior pharmacist 2010 errors collated and compared with EQUIP data

Prescribing errors at Alder Hey EQUIP 2008 Alder Hey 2010 Prevalence 124,260 newly prescribed items 11,077 errors detected Mean error rate 8.9% 3994 newly prescribed items 340 errors detected Mean error rate of 8.5% Grade of prescriber FY1 8.4% error rate FY2 10.3% error rate FY1 7.4% error rate FY2 11.3% error rate Severity of error Potentially lethal 1.7% Serious 5.6% Significant 53% Potentially lethal 1.2% Serious 5.4% Significant 37% We have continued to collect the data using the same methodology as the EQUIP study and earlier this year I supervised a couple of 4th yr medical students from Liverpool Uni who pooled all our 2010 data and then compared it to the EQUIP results. As you can see, we are not that different in terms of error rate, prescribers and severity of errors and actually come out rather favourably compared to the other 18 NW hospitals

Prescribing errors at Alder Hey Type of error Alder Hey error rate (%) Over-dose 16.5 Under-dose 10.3 Administration time incorrect/missing 13.2 Omission on admission 10 Strength/dose missing 7.1 Incorrect formulation 4.4 Drug not prescribed but indicated Duplication 3.8 IV instructions incorrect/missing No indication 2.9 Omission on TTO 2.6 Clinical contra-indication Product/formulation not specified 2.4 No signature No maximum dose 2.1 But where we do differ is in the types of error occurring. Those of us who work in paediatrics could probably have predicted that dosing errors would be much more common in paediatrics and that omissions of medication on admission much less common as many children do not have significant drug histories So we can learn from the experiences of the local hospitals but we need to concentrate on some of the specific errors that are occurring in paediatrics

Prescribing errors at Alder Hey Type of error EQUIP error rate (%) n = 10972 Alder Hey error rate (%) n = 340 % Difference in proportions (95% CI) Over-dose 8.5 16.5 8 (4.02, 11.98) * Under-dose 11.1 10.3 -0.8 (-4.08, 2.48) Administration time incorrect/missing 6.1 13.2 7.1 (3.47, 10.73) * Omission on admission 29.8 10 -19.8 (-23.1, -16.5) * Strength/dose missing 7.4 7.1 -0.3 (-3.07, 2.47) Incorrect formulation 3.7 4.4 0.7 (-1.51, 2.91) Drug not prescribed but indicated 0.8 3.6 (1.41, 5.79) * Duplication 5.5 3.8 1.7 (-0.38, 3.78) IV instructions incorrect/missing 0.9 2.9 (0.86, 4.94) * No indication 1 2.9 1.9 (0.11, 3.69) * Omission on TTO 6.2 2.6 -3.6 (-5.16, -2.04) * Clinical contra-indication 1.1 1.5 (-0.19, 3.19) Product/formulation not specified 2.4 1.4 (-0.26, 3.06) No signature 1.7 0.7 (-0.93, 2.33) No maximum dose 3.6 2.1 -1.5 (-3.06, -0.06) * But where we do differ is in the types of error occurring. Those of us who work in paediatrics could probably have predicted that dosing errors would be much more common in paediatrics and that omissions of medication on admission much less common as many children do not have significant drug histories So we can learn from the experiences of the local hospitals but we need to concentrate on some of the specific errors that are occurring in paediatrics

Prescribing errors at Alder Hey Errors more likely to occur Overdose Administration time incorrect/missing Drug not prescribed but indicated IV instructions incorrect/missing No indication for drug Errors less likely to occur Omission on admission Omission from TTO No maximum dose stated But where we do differ is in the types of error occurring. Those of us who work in paediatrics could probably have predicted that dosing errors would be much more common in paediatrics and that omissions of medication on admission much less common as many children do not have significant drug histories So we can learn from the experiences of the local hospitals but we need to concentrate on some of the specific errors that are occurring in paediatrics

Prescribing errors at Alder Hey Paracetamol, Ibuprofen, Diclofenac, Codeine, Morphine, Fentanyl, Diazepam Co-amoxiclav, Benzylpenicillin, Ciprofloxacin, Nystatin, Metronidazole, Cefotaxime Senna, Lactulose, Movicol Methotrexate Beclometasone, Salbutamol Sodium Chloride, Potassium Chloride But where we do differ is in the types of error occurring. Those of us who work in paediatrics could probably have predicted that dosing errors would be much more common in paediatrics and that omissions of medication on admission much less common as many children do not have significant drug histories So we can learn from the experiences of the local hospitals but we need to concentrate on some of the specific errors that are occurring in paediatrics

Learning from prescribing errors Regular feedback to prescribers Prioritisation for EP decision support Training & prescribing competency assessments Clinical training for pharmacists

Prescribing errors in Alder Hey We know what our level of prescribing errors is but how does this compare with others?

Future plans Comparison of electronic prescribing and handwritten prescriptions Prospective assessment of medicines administration Multi-centre study Andrea.Gill@alderhey.nhs.uk

Alder Hey Clinical Pharmacists Joseph Bowns + Aaron Andreas Kerry Dirwan