STAMP: Continuous Improvement Approach to Paediatric Prescribing
An ongoing quality improvement project focusing on paediatric prescribing and medication safety for medical, surgical and oncology patients in a district general hospital.
The Initial Problem and its Impact
The project was set up following a prescribing error made by a junior member of staff, unfamiliar with an unusual drug, then administered by nurses also unfamiliar with this drug. A baseline audit performed in January 2017 found that the average prescribing error rate on our paediatric ward was 5.4% (equivalent to 28 errors from 523 inpatient items screened).
Causes of the Problem
One of the key learning points from the incident was that both prescribing and administration errors are multifactorial and need multidisciplinary input in order for change to happen. Feedback from trainees highlighted that they felt prescribing errors were more likely due to interruptions during prescribing rather than a lack of understanding.
Project Aim Statement
- Reducing prescribing errors with the aim of reducing the overall prescribing error rate by 20% each year.
- Engaging staff to increase awareness of administration errors looking at the culture around reporting of errors.
We aimed to review the prescribing error rate data on a weekly and monthly basis. In addition, we wanted to identify why local errors were happening and improve feedback to prescribers when errors were made.
The project was launched with volunteer medical and nursing Medicines Safety Champions. The project had multi-professional input with joint leadership from the divisional lead pharmacist and two paediatric consultants who are also ‘Royal College of Paediatrics and Child Health (RCPCH) MedsIQ champions’. Trainees were also involved from inception.
The whole paediatric department is aware of the STAMP project; it is discussed in trainee induction, on the weekly departmental instant text message service and in the multidisciplinary monthly departmental governance meeting. A video narrated by two of our patients was shared on the RCPCH MedsIQ website.
PDSA Cycles / Solution(s) Tested
PDSA cycle 1
All prescribers were given name stamps to improve rates of signed prescriptions and enable individual feedback from pharmacist.
PDSA cycle 2
Aim to keep momentum of project by sharing the weekly error rate data with the paediatric team via departmental instant text message group.
PDSA cycle 3
Discussion with trainees about how they wish to receive error feedback, and from whom, so that it is meaningful and acceptable. Most preferred prompt feedback from pharmacist/consultant. Trainees found that participation in these focus groups gave them an increased sense of being involved and therefore more motivated to improve their prescribing.
PDSA cycle 4
Started sharing anonymous ‘error of the week’ examples on group text message service as a quiz, with the answer sent later in the day. Similarly, examples of good prescribing were also shared so that the STAMP project was also able to recognise individuals who have excellent standards of prescribing.
PDSA cycle 5
Departmental teaching highlighting how most errors are non-complex. Trainees attributed many of their errors to interruptions during prescribing rather than lack of understanding.
PDSA cycle 6
New guideline for surgical and orthopaedic trainees launched with dosing information for their most frequently prescribed medications.
PDSA cycle 7
Prescribing station with prescribing resources to be built on the ward to encourage prescribers to move to an interruption-free zone.
Divisional lead pharmacist collected weekly data for 9 months. The pharmacist reviewed all inpatient drug charts from Monday to Friday. Collecting data at this level is labour intensive, although we have been able to sustain this. On average, 185 prescriptions were reviewed per week.
Mean error rate was 5.2%, and worst error rate was 12.6%. Therefore, at 9 months into the project, we had not yet achieved our aim of reducing the prescribing error rate by 20%. However, this was an ongoing project, and we continued to monitor our error rate.
Data from March to August 2018 show a reduction in prescribing error rate to less than 4.3% which achieves the aim of reducing the overall prescribing error rate by 20%.
How This Improvement Will Be Sustained
The project continues, with the same consultant and pharmacy leads and new trainee involvement. The STAMP team includes registrars, junior doctors and nurse champions. By having a diverse team involved in this project we have been able to sustain it. We have continued to implement further PDSA cycles – including teaching sessions for A&E, orthopaedic and surgical doctors about paediatric prescribing. We have ensured these sessions occur at the beginning of every new rotation and have found these have been very successful.
All members of the paediatric pharmacy team are also involved in data collection and analysis. The project is discussed at the monthly paediatric governance meeting as well.
Challenges and Learnings
Our main achievement has been changing the local culture around the importance of accurate and safe paediatric prescribing and drug administration. This is now a subject frequently and openly discussed at individual, ward and management levels. The STAMP project has engaged all levels of clinical and management staff.
Collecting and sharing the error data has been the most effective way of engaging staff and keeping momentum in this project.
We feel that medication incidents are under-reported in our trust especially those that are low or no harm. Many researchers have identified barriers to incident reporting, including under-reporting and fear of blame. We need to continue to encourage staff to report all errors, even if they are no harm, near miss errors.
We hope that the prescribing station will visually highlight to young people and their carers/parents how seriously we take safe prescribing. We will continue to encourage them to advocate for medication safety particularly around issues like allergies.
Suggestions for Further Implementation
We collected data from every drug chart we screened. Other ideas could be to only include every other drug chart or even to just look at one drug chart a day. This project requires commitment from the whole multidisciplinary team for both data collection and implementation of the interventions to be successful.
Project Lead: Dr Ashifa Trivedi
Organisation: The Hillingdon Hospital