Distractions During Prescribing in a Paediatric Critical Care Unit

A one-week prospective, non-blinded audit looking at the frequency and nature of prescribing errors on a paediatric critical care unit with interventions implemented and outcomes re-audited.

The Problem

A previous audit showed that prescribing errors occurred at a frequency of 0.02 per PCCU bed days in 2013, with three cases of serious drug dose error, incorrect adjustment for renal impairment and electrolyte replacement error (1, 2). A dedicated prescribing area was introduced in 2013, but the effectiveness was undetermined. Upon observation of prescribing practice at PCCU, it was noticed that prescribers were distracted constantly, which might be contributory to the increase in prescribing errors.


An audit was designed to observe prescribers and to quantify the distractions. The effectiveness of the prescribing area was measured in terms of its usage frequency, prescribing pattern of PCCU doctors and the nature of distractions during prescribing. PCCU doctors were involved, and it was the lack of prescribing tools and high frequency of distractions at the prescribing area that deterred them from prescribing in the dedicated area. Interventions targeting their concerns were introduced.

Making the Case for Change

Access to Information

  • Prescribing tools were provided at the prescribing area:
    • latest British National Formulary
    • laminated common drug and infusion dosage charts
    • spare drug and infusion charts
    • stationary: a calculator and pens

Education and Training

  • Immediate feedback was given to staff
  • Presentations were given at various staff meetings to raise awareness
  • Safe prescribing practice was reinforced in induction programmes.

Zero Tolerance Policy

  • Prominent signage was displayed signifying that the prescribing area was an undisturbed area.

Loop Closure

  • A re-audit was carried out to assess the effectiveness of the interventions.

Our Improvement

Reduction of prescribing errors from 1.3 to 0.5 per patient bed days. There were 12 observable distractions and eight prescribing mistakes before the interventions in one week. Distractions included ward duties and interruptions from colleagues and visitors. There were 0 observable distractions and three prescribing mistakes in the re-audit. The interventions also changed the culture of prescribing practice.

Learning and Next Steps

Constant reinforcement of zero tolerance to prescribing errors and ongoing education were the key for a substantial change in prescribing practice. Modifications at the prescribing area effectively reduced observable distractions and prescribing errors.

The audit period was very short since this was the first audit on distractions and acted as a pilot study for future audits. Standardised and ongoing reviews with systematic parameters should be devised to ensure the adherence of prescribing practice and to monitor the frequency of prescribing errors.

The project was approved by the local Trust.


Project lead:  Dr Karen Man Yan Chan

Organisation: Paediatric Critical Care Unit (PCCU) at Royal London Hospital (UK)

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