Intensive Care Med (2011) 37:691–694 DOI 10.1007/s00134-010-2126-8
Catherine Warrick Hetal Naik Susan Avis Penny Fletcher Bryony Dean Franklin David Inwald
PEDIATRIC ORIGINAL
A clinical information system reduces medication errors in paediatric intensive care
B. D. Franklin Centre for Medication Safety and Service Quality, Pharmacy Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London W6 8RF, UK
1 week and (3) 6 months later. Results: There was a non-significant reduction in prescribing errors: 8.8% (95% CI 4.4–13.2) pre-implementation of EP versus 8.1% (4.4–11.8) 1 week after implementaD. Inwald ()) tion and 4.6% (2.0–7.2) 6 months Department of Paediatrics, Imperial College (St Mary’s Campus), later. The prevalence of omitted doses Wright-Fleming Institute, Norfolk Place, decreased significantly 6 months folLondon W2 1PG, UK lowing implementation, changing C. Warrick S. Avis e-mail:
[email protected] Paediatric Intensive Care Unit, from 8.1% (5.8–10.4) pre-implemenSt Mary’s Hospital, Imperial College tation to 10.6% (6.5–14.7) 1 week Healthcare Trust, Praed Street, after implementation and 1.4% (CI Abstract Purpose: To determine London W2 1NY, UK 0–2.8%) 6 months after implementathe effect of electronic prescribing tion (P \ 0.05). Conclusion: EP (EP) with a clinical information sysH. Naik B. D. Franklin tem (Intellivue Clinical Information within a clinical information system Department of Practice and Policy, School of Pharmacy, Portfolio, Philips, UK) on prescribing increases medication safety in a University of London, 29–39 Brunswick errors and omitted doses in a paedi- PICU. Square, London WC1N 1AX, UK atric intensive care unit (PICU). Methods: Prospective audit of pre- Keywords Medication error P. Fletcher Pharmacy Department, St Mary’s Hospital, scribing errors and omitted doses for Safety Electronic prescribing Clinical information system 96 h periods in three epochs: (1) Imperial College Heathcare NHS Trust, before implementation of EP, (2) Praed Street, London W2 1NY, UK Received: 22 June 2010 Accepted: 5 September 2010 Published online: 2 February 2011 Ó Copyright jointly held by Springer and ESICM 2011
Introduction Children, particularly in paediatric intensive care, are at risk of medication errors [1, 2]. Children’s drug doses are calculated on an individual basis, related to age and weight. Standardised prescriptions are therefore much less common than in the adult population. In an effort to reduce medication errors, junior doctors and nursing staff are trained in calculating correct drug doses. However, errors still occur. Electronic prescribing (EP) has been proposed as another approach to reduce prescribing errors, hence improving patient safety.
The benefits of EP in paediatric intensive care units (PICUs) in the USA have been recently described in the medical literature. A meta-analysis by van Rosse et al. [3] demonstrated a significant decrease in prescribing errors with use of computerised physician order entry, although there was no significant reduction noted in adverse drug events or mortality rates. In the UK, Shulman et al. [4] examined the impact of EP in a large tertiary adult ICU and found that the incidence of prescribing errors dropped significantly from 6.7% to 4.8% of all medication orders written. EP systems are usually linked to electronic documentation of medication administration, potentially also
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leading to fewer dose omissions. However, as yet, no study of the impact of EP has been performed in a UK PICU [5]. Computerised systems may themselves create new types of prescribing error. For example, a retrospective study [6] in a paediatric setting concluded that serious prescribing errors were uncommon with EP but were different from those seen in a paper system. It is therefore essential to evaluate changes from paper-based to EP. St Mary’s PICU at Imperial College Healthcare NHS Trust, London, admits around 400 critically ill children from across the South East of England each year. A clinical information system (Intellivue Clinical Information Portfolio (ICIP), Philips, UK) was implemented in March 2009. This was the first implementation in a UK PICU. ICIP incorporates patient observations, health care notes, drug prescribing and electronic recording of medication administration. The prescribing module includes a drug dictionary, standard weight or surface area based orders for most drugs in use on the PICU, dispensing instructions and user alerts for nursing staff when drugs are due. There is no additional clinical decision support for prescribing. The aim of this study was to evaluate the effect of this system on prescribing errors and dose omissions.
Methods We performed a prospective audit of prescribing errors and dose omissions over a 96-h period in each of three separate epochs: (1) 2 weeks prior to implementation of ICIP, (2) 1 week after implementation of ICIP and (3) 6 months after implementation of ICIP. Prescriptions assessed for prescribing errors included all forms of prescription on the medication chart except ‘‘once only medications’’. Oxygen is not a prescribed medication on our PICU. Dose omissions were recorded for regular prescription medication only. Discontinued prescriptions and medications prescribed on the day of the audit were excluded. Prescribing errors were further classified as incomplete prescriptions, insufficient information, illegible prescriptions, and errors in the prescribing decision or other. These were further subdivided according to the classification in Table 1. Each medication order could be associated with more than one prescribing error. Dose omissions in this study included wrong time errors and were defined as ‘‘failure to document the administration of a drug to a patient within 1 h of its prescribed time’’ and further subdivided into (i) doses omitted due to drug unavailability, (ii) doses omitted due to another reason or (iii) doses omitted with no documented reason. Data were collected from charts of all patients on the PICU at the time of audit, by a pharmacy student (HN) or researcher (CW), at 11 a.m. on four randomly selected weekdays, during a 2-week period for each epoch. Prescribing errors and missed doses were studied on different days. Prescription charts were reviewed for dose omissions
Table 1 Prescribing errors reported in different epochs Medication error Incomplete prescription No signature No start date No dose No frequency No route Insufficient information No patient name No hospital number Drug sensitivity box not completed Illegible prescription Clinical decision error Need for drug Inappropriate choice of drug Duplication of therapy Inappropriate dose Inappropriate frequency Inappropriate route Other error
Epoch 1 Epoch 2 Epoch 3 1 0 0 0 0
0 0 4 0 4
0 0 1 0 0
0 0 5 2
0 0 0 0
0 0 0 0
0 1 1 3 1 0 0
0 0 1 3 0 0 5
2 1 1 6 0 0 1
Epoch 1 = paper charts, Epoch 2 = 1 week after introduction of ICIP, Epoch 3 = 6 months after introduction of ICIP. ‘‘Other’’ errors in epoch 2 consisted of incomplete instructions for prescribed fluids. ‘‘Other’’ error in epoch 3 consisted of no base solution prescribed for a continuous infusion
over the previous 24-h period, up to and including the doses due at 10 a.m. on the day of data collection. The residents and fellows received routine teaching on prescribing on paper charts by the unit pharmacist during their induction and had a training session on ICIP 1 week prior to its implementation. Following data collection for epoch 2, these doctors were educated on common medication errors, particularly new errors appearing since the introduction of ICIP. There were no staffing changes in the junior doctors who could prescribe medications during the 6-month study period. Data were analysed by calculating 95% confidence intervals for proportions.
Ethics The study was registered as an audit project with Imperial College Healthcare NHS Trust.
Results Prescribing errors were evaluated in a total of 54 charts. A total of 624 prescriptions were evaluated for prescribing errors and 1,022 regularly scheduled doses were assessed for omissions. We did not identify any clinically significant change in the incidence of prescribing errors across the three epochs (Table 2). However, there was a trend towards a reduction in epoch 3 and the types of error were
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Table 2 Proportions of prescribing errors and dose omissions
Prescribing errors (n/number of drug prescriptions) Omitted doses (n/total doses due)
Paper (epoch 1)
ICIP (epoch 2)
ICIP (epoch 3)
14/159 95% 43/528 95%
17/208 95% 23/216 95%
12/257 (4.6%), 95% CI = 2.0–7.2% 4/278 (1.4%), 95% CI = 0–2.8%
(8.8%), CI = 4.4–13.2% (8.1%), CI = 5.8–10.4%
different pre- and post-implementation of ICIP. Prescriptions with insufficient information and illegible prescriptions were most common in the paper system, but were eradicated following introduction of ICIP. Instead, incomplete prescriptions, errors in the prescribing decision and ‘other’ errors were the main causes of error with ICIP (Table 1). A number of new errors appeared following introduction of ICIP. In epoch 2, incorrect infusion rates were sometimes selected for continuous infusions or no base solution was prescribed. In epoch 3, incorrect selection occurred from the multiple dosage options available for some drugs, particularly aciclovir. The proportion of omissions was significantly reduced following introduction of ICIP, from 8.1% to 1.4% of doses. By epoch 3 dose omissions due to reasons other than drug unavailability were completely abolished, and there were no doses omitted without a properly documented reason (Table 3).
Discussion This is the first evaluation of EP using a clinical information system in paediatric critical care in the UK [5]. This evaluation demonstrated that introduction of this system in a PICU over a 6-month period reduced omission errors and possibly prescribing errors. The types of prescribing error also changed as it was no longer possible to have illegible prescriptions or prescriptions with no drug sensitivity box completed. Furthermore, most drugs had standardised weight based prescriptions programmed into the system by the pharmacy and nursing teams. These changes clearly improved the safety of paediatric prescribing. However, with the initial evaluation of the EP system some common new errors were found, for example, infusions or maintenance fluids were often prescribed with no base solution or daily rate. The clinicians were educated about these common errors and prescribing error rates improved by the second ICIP evaluation (epoch 3). In relation to dose omissions, as ICIP flags up overdue medications by alerts in an electronic work book it is less likely that the bedside nurse will miss a dose. Nurses also
(8.1%), CI = 4.4–11.8% (10.6%), CI = 6.5–14.7%
Table 3 Dose omissions reported in different epochs
Total number of doses due Total number of omitted doses % doses omitted Doses omitted due to ‘‘drug unavailable’’ Doses omitted due to ‘‘other reason’’ Doses omitted with no reason given
Epoch 1
Epoch 2
Epoch 3
528 43 8.1% 9
216 23 10.6% 4
278 4 1.4% 4
15 19
4 15
0 0
have to document the reason a drug was held e.g. antibiotic level pending. These features are very difficult to achieve in a paper based system. Limitations This study was limited by the pre- and post-design without a control group and also by the small sample size and time period examined. The impact of introducing a computerised prescribing system on patient outcomes was also not studied and we did not explore the clinical importance of the errors identified.
Conclusion EP on ICIP was associated with a significantly lower incidence of dose omissions, and a tendency toward a lower incidence of prescribing error. Some new types of errors were introduced. Although a clinical information system can reduce the incidence of drug errors in a PICU, ongoing education and training is critical to ensure that new errors are not introduced and manufacturers must remain responsive to the needs of clinicians, providing solutions to commonly seen problems as they are encountered. Acknowledgments Dr Inwald is grateful for support from the NIHR Biomedical Research Centre funding scheme. The Centre for Medication Safety and Service Quality is affiliated to the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust which is funded by the National Institute of Health Research.
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