Preventing Alteration of Paediatric Prescriptions

Preventing alteration of paediatric medical prescriptions in a general paediatric ward where medication incidents represented around 1 in 5 of reported incidents.

The Problem

Medication incidents are common in acute paediatric care representing about 1 in 5 reported incidents on the Paediatric ward in Craigavon Hospital. Just over half of medication incidents result from prescription errors.

While alteration of prescriptions is common and admitted by a number of doctors on questioning they are rarely reported on the Datix Incident reporting system though they can impair legibility of prescriptions and therefore result in confusion of drug name, dose or frequency.


To stop alteration and improve legibility of prescriptions in paediatrics in Craigavon Area Hospital by June 2014.

Our Improvement

The project had involvement of the associate medical director and ward nurse manager initially. A presentation of the project was given to paediatric medical and nursing teams as well as the surgical, anaesthetic and dermatology teams to explain the importance of stopping altering prescriptions.

The proportion of altered drug Kardexes was measured by sampling 5 Kardexes weekly.

Prescribers were provided with two simple messages: “Stop altering prescriptions” and “Nurses will contact prescribers to rewrite prescriptions if altered”. This led to a significant fall in altered prescriptions from a median of 2 each Kardex to a median of 0. Prescribers were then provided with three further simple messages: “Read your prescription after writing it”, “Could drug name, dose or time be confused with anything else?” and “Nurses will contact prescribers to rewrite prescriptions if illegible.” This led to a reduction in the frequency of illegible prescriptions.

Learning and Next Steps

Unfortunately I was not able to sustain the changes as I was not able to continue the project after June 2014. This has led to new medication incidents resulting from alteration of prescriptions.

The project was carried out with the Cross Border Patient Safety Programme Organised by CAWT (Cooperation and Working Together) and the HSC Patient Safety Forum.


Project lead: Dr David Grier, Consultant Paediatrician

Organisation: Southern Health and Social Care Trust, Northern Ireland

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