ImPrint: Simplified Infusion Prescribing
Creating a standard, simplified monograph for prescribing high risk drugs on an intensive care unit.
Drug errors are the single most common incident in health care and infusions in an intensive care environment are often unfamiliar and infrequently administered. This creates conditions with the potential for serious avoidable harm.
It is likely that your unit uses monographs to aid prescribing but in our experience these are often verbose, pharmacy focused and do not always facilitate safe prescribing or administration. In high pressure situations these monographs may even contribute to errors.
We set out to simplify and restructure the information we provide creating a layout which can simply be transcribed – an imprint of the final prescription.
Reduce the number of avoidable errors made by staff when prescribing unfamiliar medications under stress or pressure. This aim should be achieved by simplifying our monographs without removing pharmacological information. The new layout (tool) should restructure the monographs to change the focus to the act of prescribing and separately administration rather than pharmacokinetics.
Most units will recognise that they already have monographs and consider this irrelevant but we challenge you to test the ease of use and error rate for clinical staff under pressure. The new layout (tool) created a simplified step by step explanation for the prescriber which reflects directly the fields required on the drug card.
It removes extrapolation or the need for interpretation. Calculations are presented exactly as they need entering into a calculator. The same process was performed for the guidance on administration. Important pharmacological information such as Y-site compatibility was transferred to the rear of the monograph recognising that this remains important but not immediately vital to prescribing.
Prior to implementation we undertook a small crossover trial involving 30 critical care physicians, cardiologists and senior nurses. We demonstrated that simplification improved serious errors (9 to 4, p 0.001), reduced median prescribing times (210 to 136 seconds, p 0.05) and crucially reduced the most serious errors to zero. The new format was much more popular.
We are now reviewing our most common infusions to bring them in line with the new format.
Suggestions for Further Implementation
The intention is to adapt this format to work within the MIST (Making It Safer Together) collaborative.
The tool lends itself for easy and quick development of further monographs for common IV drug. Finally there is the capacity to convert these simply into applications for electronic prescription generation.
Challenges and Learning
Raising support was achieved once the consultant body and senior nursing staff appreciated the challenges faced with the existing monographs. Cardiologists and intensivists are competitive people so a prescription competition against the clock served this purpose of proof very well. Immediately they recognised the potential risks with the existing format and how challenging prescribing under pressure was – created artificially by time pressure in the competition.
We still need to look at whether fixed rate or fixed drug amount is best practice for IV infusions and would welcome other units experience here.
The format was approved for use by our regional cardiac intensive care unit.
Project Lead: Mark Fenner, Paediatric Registrar; Simon Robinson, Paediatric Consultant.
Organisation: University Hospitals of Leicester