1. Do distractions increase the number of prescribing errors in paediatric intensive care? Adam Sutherland, Senior Clinical Pharmacist, Paediatric Critical Care & metabolic Medicine Pharmacy Central Manchester University Hospitals NHS Foundation Trust

2. The Impact of Distractions on Prescribing Errors in PICU Adam Sutherland (Pharmacy, RMCH) Laura Jonhstone (The Medical School, UoM) Kay Hawkins (PICU, RMCH)

3. Established error rate 12.1 – 26% –Seasonal and ?dependent on workload and unit acuity Interventions to reduce this: –Pre-printed prescription charts –Enhanced induction training in medicines management –Introduction of “Prescribing Areas” Background

4. Inspiration 1981 – FAA Regulation 14CFR121: “…prohibit crew member performance of all non-essential duties or activities during “high- threat” times such as taxi, take-off, landing and operations below 10000ft.” “ Sterile cockpit ”

5. Prescribing areas introduced on the back of three notable papers: –Hohenhaus(2005): “Sterile Cockpit” in healthcare –Abeysekera (2008) noted 37% of prescribing errors due to inattention –Booth (2012) showed a 45% reduction in prescribing errors over 52 weeks after the introduction of “Zero Tolerance Prescribing.” Background

6. Identify how often the prescribing process is distracted Elucidate the nature of those distractions Elucidate the relationship between distraction and prescribing error Evaluate the efficacy of our designated “prescribing areas” Aims & Objectives

7. Single blind prospective observational study –Observer (LJ) was not blinded to the prescribing process –Reviewer (AS) was blind the prescribing process Data collected over a 20 day period –Covered days, nights and weekends –4-hour observation to minimise observer fatigue –Prescriptions reviewed retrospectively Established, validated monitoring tool (Dornan 2010) Methodology

8. n = 189 : 200 prescribing episodes reviewed; 11 lost to follow up Results Distraction YesNoTotal ErrorYes162137 No38114152 Total 54135189 There is a significant association between distraction and error Χ 2 = 0.028

9. Location of Distractions Results BedsideNurses' StationPrescribing area Distracted 33 (30)8 (15)13 (50) No Distraction 76 (70)48 (85)13 (50) 109 (100)54 (100)26 (100)

10. Nature of Distraction Results Necessary Emergency (any pt) Query from staff (Nurse, Medic, Other Professional) Mixed Infusion pump alarm Ventilator alarm Avoidable General talking Telephone call

11. Results Error? YesNoTotal Necessary (%) 8 (27) 22 (73) 30 Mixed (%) 1 (14) 6 (86) 7 Avoidable (%) 6 (35) 11 (65) 17 Total number of distractions54 Distraction Events

12. Results

13. Errors caused by distraction Results Error TypeTotal number of errors (%) Allergy1 (2.7) Ambiguous order3 (8.1) Incorrect concentration1 (2.7) Incorrect dose21 (56.8) Incorrect frequency1 (2.7) Incorrect nomenclature1 (2.7) Incorrect route5 (13.5) Non standard notation1 (2.7) Not formulae choice1 (2.7) Time omitted1 (2.7) Wrong strength1 (2.7) Total37 (100)

14. Prescribing Areas have been ineffective –Under utilised –Under policed Distractions are too common –Classification and acceptance –Prescribing is still a “Low Value Task” Discussion

15. Booth et al ZTP had two arms: –Prescribing areas –Consultant chart review –Clarity of “rules” and standards –Empowerment of nursing staff Discussion

16. There is a significant correlation between distraction and prescribing errors –But this is a very small study so indicative only. Further study is warranted in the following areas: –Causes of prescribing errors –Aetiology of distractions Conclusions

17. Unit culture may contribute adversely to prescribing errors Conclusions Reducing prescribing errors is a CULTURAL, as well as procedural, challenge