Document Type : Brief Report
Pediatric Specialist Registrar, Health Education and Improvement Wales, UK.
Nurse Educator, Department of Nursing, Morriston Hospital, Swansea, UK.
Lead Pediatric Pharmacist, Morriston Hospital, Swansea, UK.
Consultant Paediatrician, Morriston Hospital, Swansea, UK.
Prescribing and medication administration errors are common themes in Pediatrics. There is growing international evidence that the regular occurrence of such errors carries a high potential for unintended harm to patients. Within our Trust, a high percentage of reported pediatric incidents relate to medication errors. The most-commonly reported themes were incorrect dosing and omission of regular medication. The aim of our project was to reduce medication errors by at least 10%.
Materials and Methods:
To achieve our aim, we devised a structured educational program was devised by a tripartite alliance (Nursing, Medicine, Pharmacology) and rolled out to nursing staff and medical trainees. An initial prospective audit was undertaken, followed by two PDSA (Plan-Do-Study-Act) cycles.
Following the intervention, the percentage of medication errors decreased from 89.3% to 12.1%, with a comparative 51.3% decrease in significant errors and a complete elimination of serious/potentially lethal errors.
In view of our results, we hope that tripartite alliances may be used as a model for inter-professional collaboration across healthcare systems.