Personalised performance feedback reduces narcotic prescription errors in a NICU

Area of Science:

• Neonatal medicine
• Patient safety
• Healthcare quality improvement

Background:

• Neonates face high risks of morbidity and mortality due to medication prescribing errors.
• Existing computerized alerts have proven insufficient in preventing these errors.
• Continuous medication errors pose a significant threat in neonatal intensive care units (NICUs).

Purpose of the Study:

• To implement and assess a feedback system for medication prescribing errors in the NICU.
• To measure the impact of direct error feedback on the frequency of medication errors.
• To specifically evaluate the effect on antibiotic and narcotic prescribing errors.

Main Methods:

• A multidisciplinary team utilized Plan-Do-Study-Act cycles to develop a feedback system.
• Prescribing errors were communicated directly to providers every two weeks in the NICU.
• The primary outcome measured was the time interval between medication prescribing errors.

Main Results:

• The time between narcotic prescribing errors increased from 3.94 to 22.63 days, an 83% improvement.
• The intervention demonstrated a significant reduction in narcotic prescribing errors.
• No significant impact was observed on the frequency of antibiotic prescribing errors during the study period.

Conclusions:

• A structured system for communicating prescribing errors can effectively reduce certain types of medication errors in neonates.
• Direct feedback to providers is a viable strategy for improving medication safety in the NICU.
• Targeted interventions are crucial for addressing specific medication error types in vulnerable patient populations.