Zero tolerance prescribing: A strategy to reduce prescribing errors on the paediatric intensive care unit

Intensive Care Medicine

Volumn 38, Issue 11, 2012, Pages 1858-1867

  Booth, Rachelle ^a   Sturgess, Emma ^a   Taberner Stokes, Alison ^a   Peters, Mark ^a,b  

^a GREAT ORMOND STREET HOSPITAL   (United Kingdom)

^b UNIVERSITY COLLEGE LONDON   (United Kingdom)

Author keywords

Improvement; Intensive care; Pediatrics; Prescribing errors; Safety; Zero tolerance

Indexed keywords

ARTICLE; CHILD; CLINICAL PRACTICE; DRUG OVERDOSE; DRUG UNDERDOSE; FEMALE; HUMAN; INFANT; INTENSIVE CARE UNIT; MAJOR CLINICAL STUDY; MALE; MEDICATION ERROR; OBSERVATIONAL STUDY; PATIENT SAFETY; PRESCHOOL CHILD; PRESCRIPTION; PROSPECTIVE STUDY; ZERO TOLERANCE PRESCRIBING POLICY;

CHILD; CHILD, PRESCHOOL; DRUG PRESCRIPTIONS; FEEDBACK; FEMALE; GREAT BRITAIN; HUMANS; INFANT; INFANT, NEWBORN; INTENSIVE CARE UNITS, PEDIATRIC; MALE; MEDICATION ERRORS; MEDICATION SYSTEMS; PROSPECTIVE STUDIES; QUALITY IMPROVEMENT;

EID: 84868206198     PISSN: 03424642     EISSN: 14321238     Source Type: Journal    
DOI: 10.1007/s00134-012-2660-7     Document Type: Article

References (41)

1. Moyen E, Camire E, Stelfox HT (2008) Clinical review: medication errors in critical care. Crit Care 12:208. doi: 10.1186/cc6813
2. Department of Health (2004) Building a safer NHS for patients: improving medication safety. The Stationery Office, London
3. Camire E, Moyen E, Stelfox HT (2009) Medication errors in critical care: risk factors, prevention and disclosure. CMAJ 180:936-943
4. McDowell SE, Ferner HS, Ferner RE (2009) The pathophysiology of medication errors: how and where they arise. Br J Clin Pharmacol 67:605-613
5. Kane-Gill SL, Jacobi J, Rothschild JM (2010) Adverse drug events in intensive care units: risk factors, impact, and the role of team care. Crit Care Med 38:S83-S89
6. Ghaleb MA, Barber N, Franklin BD, Wong IC (2010) The incidence and nature of prescribing and medication administration errors in paediatric inpatients. Arch Dis Child 95:113-118
7. Mani V, Wheeler DW (2010) Drug form and expression of concentration may also lead to prescription errors. Drug Saf 33:167-168
8. Lesar S (2006) Medication safety in critically ill children. Clin Ped Emerg Med 7:215-225
9. Department of Health (2000) An organisation with a memory: report of an expert group on learning from adverse events in the NHS. The Stationery Office, London
10. Kaushal R, Bates DW, Abramson EL, Soukup JR, Goldmann DA (2008) Unitbased clinical pharmacists' prevention of serious medication errors in pediatric inpatients. Am J Health Syst Pharm 65:1254-1260
11. Miller MR, Robinson KA, Lubomski LH, Rinke ML, Pronovost PJ (2007) Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Qual Saf Health Care 16:116-126
12. Al-Jeraisy MI, Alanazi MQ, Abolfotouh MA (2011) Medication prescribing errors in a pediatric inpatient tertiary care setting in Saudi Arabia. BMC Res Notes 14:294
13. Alagha HZ, Badary OA, Ibrahim HM, Sabri NA (2011) Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt. Acta Paediatr 100:e169-e174
14. Montesi G, Lechi A (2009) Prevention of medication errors: detection and audit. Br J Clin Pharmacol 67:651-655
15. Leape LL (1995) Preventing adverse drug events. Am J Health Syst Pharm 52:379-382
16. Dean B, Barber N, Schachter M (2000) What is a prescribing error? Qual Health Care 9:232-237
17. Slater A, Shann F, Pearson G (2003) PIM2: a revised version of the paediatric index of mortality. Int Care Med 29:278-285
18. Franklin BD, Reynolds M, Shebl NA, Burnett S, Jacklin A (2011) Prescribing errors in hospital inpatients: a threecentre study of their prevalence, types and causes. Postgrad Med J 87:739-745
19. Nichols P, Copeland TS, Craib IA, Hopkins P, Bruce DG (2008) Learning from error: identifying contributory causes of medication errors in an Australian hospital. Med J Aust 188:276-279
20. Leonard MS, Cimino M, Shaha S, McDougal S, Pilliod J, Brodsky L (2006) Risk reduction for adverse drug events through sequential implementation of patient safety initiatives in a children's hospital. Pediatrics 118:e1124-e1129
21. Alvarez G, Coiera E (2005) Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform 74:791-796
22. Tang Z, Weavind L, Mazabob J, Thomas EJ, Chu-Weininger MY, Johnson TR (2007) Workflow in intensive care unit remote monitoring: a time-and-motion study. Crit Care Med 35:2057-2063
23. Hohenhaus SM, Powell SM (2008) Distractions and interruptions: development of a healthcare sterile cockpit. Newborn Infant Nurs Rev 8:108-110
24. Safe Medicine Use Expert Committee (2010) Chapter 1066: physical environments that promote safe medication use. In: USP33-NF28, The United States Pharmacopeia/National Formulary. United States Pharmacopeial Convention. Available via http://www.usp.org/sites/default/files/usp-pdf/EN/USPNF/c1066.pdf Accessed 20 May 2012
25. Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy Press, Washington, DC
26. Trooskin SZ (2002) Low-technology, cost-efficient strategies for reducing medication errors. Am J Infect Control 30:351-354
27. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AW, Pronovost P (2003) Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med 31:1006-1011
28. Ferner RE (2009) The epidemiology of medication errors: the methodological difficulties. Br J Clin Pharmacol 67:614-620
29. Wheeler SJ, Wheeler DW (2005) Medication errors in anaesthesia and critical care. Anaesthesia 60:257-273
30. Ghaleb MA, Barber N, Dean Franklin B, Wong IC (2005) What constitutes a prescribing error in paediatrics? Qual Saf Health Care 14:352-357
31. Potts AL, Barr FE, Gregory DF, Wright L, Patel NR (2004) Computerized physician order entry and medication errors in a pediatric critical care unit. Pediatrics 113:59-63
32. Kadmon G, Bron-Harlev E, Nahum E, Schiller O, Haski G, Shonfeld T (2009) Computerized order entry with limited decision support to prevent prescription errors in a PICU. Pediatrics 124:935-940
33. Vaidya V, Sowan AK, Mills ME, Soeken K, Gaffoor M, Hilmas E (2006) Evaluating the safety and efficiency of a CPOE system for continuous medication infusions in a pediatric ICU. AMIA Annu Symp Proc 2006:1128
34. Han YY, Carcillo JA, Venkataraman ST, Clark RS, Watson RS, Nguyen TC, Bayir H, Orr RA (2005) Unexpected increased mortality after implementation of a commercially sold computerized physician order entry system. Pediatrics 116:1506-1512
35. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL (2005) Role of computerized physician order entry systems in facilitating medication errors. JAMA 293:1197-1203
36. Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH (2006) Types of unintended consequences related to computerized provider order entry. J Am Med Inform Assoc 13:547-556
37. Walsh KE, Adams WG, Bauchner H, Vinci RJ, Chessare JB, Cooper MR, Hebert PM, Schainker EG, Landrigan CP (2006) Medication errors related to computerized order entry for children. Pediatrics 118:1872-1879
38. Redwood S, Rajakumar A, Hodson J, Coleman JJ (2011) Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. BMC Med Inform Decis Mak 11:29
39. Barber N (2010) Electronic prescribing - safer, faster, better? J Health Serv Res Policy 15(S1):64-67
40. Caldwell NA, Power B (2011) The pros and cons of electronic prescribing for children. Arch Dis Child 97:124-128
41. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO (2009) Does computerized provider order entry reduce prescribing errors for hospital inpatients? A systematic review. J Am Med Inform Assoc 16:613-623