G126 Zero Tolerance Multidisciplinary Approach Can Minimise Medication Errors in Paediatrics. (4th June 2013) - Dissanayake, PV
Abstract : Introduction: Children are at increased risk of medication errors due to factors such as body weight, composition, age and organ immaturity and also being unable to challenge or take ownership. Despite standards being set on safe prescribing (BNF & Trust Prescribing Policy, 2007), errors are frequent during prescribing, dispensing and administration of medications as shown by the EQUIP study (2009). Method: In a secondary-care setting, each medication error was reported as a clinical incident via Trust Incident Reporting System and was graded (green, yellow, amber and red) according to the risk matrix. Baseline data was collected prospectively of all medication errors from 1st January to 30th September 2011, and compared with data for the same period in 2012. A zero-tolerance policy to drug errors was introduced in October 2011 by setting up a Multidisciplinary Medication Safety Group which implemented changes which included, increasing the awareness of medication safety amongst all groups of members of staff who received targeted training in prescribing, dispensing and administration. Irrespective of the severity of the incident, table-top reviews were convened and members of staff were requested to reflect upon their practise. (Details will be discussed). Results: Baseline medication errors of 49(in 2011) decreased to 20(in 2012) following the intervention despite a 30% increase in the incidence of overall incident reporting in 2012. Statistics (paired T-test) was highly significant (p < 0.0001). There were no red medication errors in either year, and the amber category improved best.(by 76%). Inpatient wards had high volume of errors (69% and 65%) but also the best improvement (by 62%). Conclusion: It is possible to reduce medication errors by a zero-tolerance approach, with changes implemented through a multidisciplinary team. We are committed to ensuring patient safety in this high risk high volume area by continued monitoring. This is an example of upholding the Hippocrates Oath; primum non nocere, as we demonstrated the ability of minimising iatrogenic harm by instituting good medical practise.