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01-01-2016 | Original Article

A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates

Authors: David Palmero, Ermindo R. Di Paolo, Lydie Beauport, André Pannatier, Jean-François Tolsa

Published in: European Journal of Pediatrics | Issue 1/2016

Abstract

The objective of this study was to assess whether the introduction of a new preformatted medical order sheet coupled with an introductory course affected prescription quality and the frequency of errors during the prescription stage in a neonatal intensive care unit (NICU). Two-phase observational study consisting of two consecutive 4-month phases: pre-intervention (phase 0) and post-intervention (phase I) conducted in an 11-bed NICU in a Swiss university hospital. Interventions consisted of the introduction of a new preformatted medical order sheet with explicit information supplied, coupled with a staff introductory course on appropriate prescription and medication errors. The main outcomes measured were formal aspects of prescription and frequency and nature of prescription errors. Eighty-three and 81 patients were included in phase 0 and phase I, respectively. A total of 505 handwritten prescriptions in phase 0 and 525 in phase I were analysed. The rate of prescription errors decreased significantly from 28.9 % in phase 0 to 13.5 % in phase I (p < 0.05). Compared with phase 0, dose errors, name confusion and errors in frequency and rate of drug administration decreased in phase I, from 5.4 to 2.7 % (p < 0.05), 5.9 to 0.2 % (p < 0.05), 3.6 to 0.2 % (p < 0.05), and 4.7 to 2.1 % (p < 0.05), respectively. The rate of incomplete and ambiguous prescriptions decreased from 44.2 to 25.7 and 8.5 to 3.2 % (p < 0.05), respectively.

Conclusion: Inexpensive and simple interventions can improve the intelligibility of prescriptions and reduce medication errors.

What is Known:

• Medication errors are frequent in NICUs and prescription is one of the most critical steps.

• CPOE reduce prescription errors, but their implementation is not available everywhere.

What is New:

• Preformatted medical order sheet coupled with an introductory course decrease medication errors in a NICU.

• Preformatted medical order sheet is an inexpensive and readily implemented alternative to CPOE.

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Title: A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates
Authors: David Palmero
Ermindo R. Di Paolo
Lydie Beauport
André Pannatier
Jean-François Tolsa
Publication date: 01-01-2016
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Pediatrics / Issue 1/2016
Print ISSN: 0340-6199
Electronic ISSN: 1432-1076
DOI: https://doi.org/10.1007/s00431-015-2607-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

A bundle with a preformatted medical order sheet and an introductory course to reduce prescription errors in neonates

Abstract

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

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