A novel system of prescribing feedback to reduce errors: A pilot study

Abstract

Prescribing errors are one of the most common adverse events in healthcare. Previous research in patient safety has highlighted the importance of error awareness education to enhance professional attitudes and reduce errors. Systems of contemporaneous prescribing feedback previous researched are limited by shift working. We introduced a departmental prescribing feedback system to address this limitation. We used a Before and After study design. The setting was a single inpatient paediatric unit and 26 Paediatric medical staff participated. Baseline assessment of prescribing errors and safety attitudes took place, followed by 3 weekly reassessments over a 3 month period. After each assessment, a feedback poster was displayed and emailed to staff, giving general and anonymous personalised feedback. 205 medication orders representing 3,280 opportunities for error were examined. There was a statistically significant reduction in the error rate (P < 0.0001) between baseline (8.8%, 69 out of 784 possibilities for error) and completion at 3 months (1.8%, 12 out of 656 possibilities for error). There was an improvement in patient safety attitudes, but this was not statistically significant. This pilot project has demonstrated an error feedback system can reduce errors. This technique could be easily adopted and introduced, warranting further research.