P15 Using prescribing nudges to reduce medication errors: paracetamol on paediatric intensive care

Abstract

Aim Paracetamol is widely available and its safety profile is relatively good. However, the risk associated with a paracetamol overdose is much greater in a neonate than that associated with an adult. In 2018, 8% of paediatric medication errors related to the use of paracetamol, including three 10x overdoses. These irregular but serious risks are difficult to manage over time due to degradation of heightened awareness. The aim of this project was to improve the prescribing quality of IV paracetamol on PICU and prevent recurrence of a 10-fold overdose by the implementation of multi-level changes. Method Electronic prescribing (EP) has been in use on our unit since 2016. Small changes (prescribing nudges) in the configuration of the EP system can be used to improve prescribing quality. Forced functions, automation and standardisation have been found to be more effective in this than more traditional education and training methods.1 2 The changes implemented in January 2019 were as follows: Prescription details were downloaded from the EP system for 3 month periods pre and post changes. he data was audited by pharmacy undergraduate students for prescribing accuracy. Results The forced function, automation and standardisation options were implemented with 100% compliance. The ‘consultant approval’ rule was followed in 23% of cases. Consultant review led to a 58.6% reduction of IV paracetamol prescriptions on the unit and zero prescriptions for the first 2 months post implementation. The usage of oral paracetamol increased accordingly. This change corresponded to an overall reduction rate of 41.7% for intravenous paracetamol prescriptions. Conclusions This project demonstrates how changes that increase automation within prescribing can reduce error and that implementation is more successful than education. A limitation of our data analysis was that we did not measure the effect on pain relief or pain scores in the patients who did not receive IV paracetamol compared to those who did. References 1. Cafazzo JA, et al . From discovery to design: the evolution of human factors in healthcare. Healthcare Quarterly 2012; 15 : 24–29. 2. Patel Ms, et al . Nudge units to improve the delivery of healthcare NEJM 2018; 378 : 214–216.