Creating a Medication Safety Culture in PICU

A project to create medicines safety culture, empowering staff to say no to interruptions/ improving the reliability of incident reporting.

The Problem

An anonymous audit of adverse drug events was performed on our paediatric intensive care units, which found numerous medication errors occurring. These errors were also being significantly underreported through the electronic incident reporting system.

It was felt that the busy nature of the units was contributing to the error rate, as staff were often unable to prescribe or administer medicines without interruption, potentially leading to mistakes. There also seemed to be a general culture discouraging incident reporting, as staff felt that they were a tool for blame, with no benefit seen in completing them.


The main aim of this project was to reduce the rate of adverse drug events in our units, by identifying and minimising potential systematic sources of error. The initial focus for intervention was the elimination of distractions during the prescribing, preparing and administration of medication.

However, in order to assess the effect of our changes, as well as find new areas for intervention, we needed a reliable method of data capture. Therefore, the other aim of the project was to increase the proportion of errors that were electronically reported, improving the reliability of our incident reporting system.

Making the Case for Change

The initial adverse drug event audit findings were discussed at the local clinical practice meeting, and the findings were cascaded to staff via email and a poster campaign. It was agreed that a culture change was needed, from a ‘blame culture’ to one of ‘fair accountability’, with incident reporting seen as a tool for change, and staff given feedback on its positive outcomes. Staff also needed to make medicine safety a priority, with time, space and resources dedicated to empowering staff to say no to interruptions during prescribing and administration.

Junior doctor and nursing involvement was considered a necessity in implementing this change, as they did the majority of the prescribing and administering. Therefore, medical and nursing “Safety Champions” were chosen in each unit, tasked with disseminating information, promoting good prescribing and administration habits and leading on-going audits.

Our Improvement

Dedicated prescribing areas were created, equipped with drug monographs, BNFs, calculators and headphones to block out extraneous noise. A medicines guideline was developed, instructing prescribers to use the dedicated areas and nurses to wear special aprons while preparing and administering medicines, protecting them from interruption. A poster campaign also empowered staff to say no to interruptions.

Staff were encouraged to report errors under assurance that reports were solely used to highlight systematic issues, with staff receiving feedback on their outcomes.

Monthly audits were performed, assessing the number and type of errors occurring, with comparison to the electronic reporting system.

Learning and Next Steps

Monthly audits showed an increase in the proportion of medication errors being reported, suggesting that incident reporting can be improved through a targeted programme including appropriate feedback and a ‘no blame’ approach. However, despite some improvement, underreporting of errors still continues.

Staff have been empowered to prescribe and administer medications without interruption, but it remains difficult to accurately measure the effect of this intervention without a reliable screening and reporting method. The monthly audit process has resulted in nursing staff fatigue, resulting in unreliable reporting, and therefore its usefulness has become limited – a new approach is currently being planned.

The project was approved by the local Trust.


Project lead: Ahmed Osman

Organisation: University Hospitals of Leicester

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