A 1999 report by the Institute of Medicine estimated as many as 98 000 individuals die annually in hospitals as a result of medical errors.1
In a random sampling of 30 000+ medical records by the Harvard Medical Project, as many as 19% of the 1133 adverse events found were medication related.2
Despite efforts to solve this problem, medication-related adverse events continue to be highly prevalent and particularly harmful to a rapidly growing neonatal population.3
Medication prescribing errors, the focus of this report, are a significant contributor to medication-related adverse events. The need to pay attention to rapidly changing weights and drug dosing based on multiple parameters, such as weight and gestational age, as neonatal prescribing requires vigilance both at dose initiation and maintenance to reduce medication errors.5–8
Doing ‘the five rights (right drug to the right patient, at the right dose, route and time)’ of medication management remains a huge challenge especially for prescribers. Aside from being the most frequent type of medication errors, prescribing errors have significant downstream effects. In our institution, it is common for the pharmacy to process approximately 34 orders per hour; since resolving a prescribing error takes an estimated 15 min, each prescribing error can, potentially, delay processing of as many as seven other medications. In addition, reconciling prescribing errors adds error opportunities by causing workflow interruption and distractions for pharmacist and prescribers. By the time errors are intercepted downstream, significant operational cost (time, resources and personnel) has been wasted.
Alerts built into computerised physician order entry (CPOE) systems have made significant progress in preventing prescribing errors. But stifled by unintended negative consequences and high degrees of alert override,9
they have not been as effective in preventing prescribers from making errors, as previously hoped.11–13
An alternative strategy worth exploring in the prevention of errors is the use of performance feedback to help providers prescribe more carefully.
Published literature, and our experience, indicate that there is low self-awareness of how many errors prescribers make.14
Hence, informing prescribers about specific errors they have made, and how to avoid them in the future, may be an important step to engaging them into a team effort to reduce prescribing errors. The importance of feedback and reminders in efforts to improve compliance with clinical care guidelines has been emphasised by published literature.16
To this point, similar approaches for safe practice guidelines show that direct constructive feedback to prescribers about their errors, and ways to avoid them in the future, can reduce errors.7
Some literature suggests that delivering feedback closer to the moment of action has more impact on the recipient.21
The purpose of this paper is to report the development of a prescribing error feedback programme, and its impact on narcotic prescribing errors. We also discuss how an approach to synergise appropriate personnel, processes and tools was important to the programme's successful implementation.
Local setting and problem
This study took place in a major 75-bed neonatal intensive care unit (NICU) regional referral centre. The unit uses an electronic health record system with computerised order entry capabilities. The existing CPOE alerts have limited impact, as demonstrated by high override rates similar to the reported literature. Although an electronic formulary is available on the intranet, it cannot be accessed directly from the CPOE system when it is most needed during order entry. On average, 195 medications are prescribed per day by residents, nurse practitioners, physician assistants and attending physicians in the NICU. Everyday, pharmacists review these orders in addition to approximately 3200 other orders from other hospital units, processing approximately 34 orders per hour. Within this hour, the pharmacists have the arduous task of detecting any prescribing errors and calling prescribers for clarification or correction. These ‘incidents’ are recorded in an electronic database that can be queried for quality control activities.
Review of prescribing errors indicated that most errors were associated with narcotics—an Institute for Safe Medication Practices-defined high-alert medication. Although pharmacists intercept most narcotic errors, those that reach neonates can cause respiratory and neurological depression leading to emergent intubation and mechanical ventilation. Therefore, reducing narcotic errors was an important safety goal of this project.