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

2. 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

3. 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

4. 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

5. EQUIP Study EQUIP 2008 Prevalence 124,260 newly prescribed items
11,077 errors detected
Mean error rate 8.9%
Grade of prescriber
FY % error rate
FY % error rate
Severity of error
Potentially lethal 1.7%
Serious %
Significant %
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

6. 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

7. 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
FY % error rate
FY % error rate
FY % error rate
FY % error rate
Severity of error
Potentially lethal %
Serious %
Significant %
Potentially lethal %
Serious %
Significant %
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

8. 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

9. 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

10. 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

11. 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

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

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

14. Future plans
Comparison of electronic prescribing and handwritten prescriptions
Prospective assessment of medicines administration
Multi-centre study

15. Alder Hey Clinical Pharmacists Joseph Bowns + Aaron Andreas
Kerry Dirwan