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A novel system of prescribing feedback to reduce errors: A pilot study.
Morris Gordon1, Bratati Bose-Haider
1Faculty of Health and Social Care, University of Salford, Salford, UK. morris@betterprescribing.com
The International Journal of Risk & Safety in Medicine
|November 9, 2012
Summary
A new prescribing feedback system significantly reduced medication errors in a pediatric unit. This approach offers a practical method for improving patient safety and warrants further investigation.
Area of Science:
- Healthcare quality improvement
- Patient safety research
- Medical education
Background:
- Prescribing errors are a common adverse event in healthcare.
- Error awareness education is crucial for improving professional attitudes and reducing errors.
- Existing prescribing feedback systems face limitations due to shift work.
Purpose of the Study:
- To introduce and evaluate a departmental prescribing feedback system to overcome limitations of previous methods.
- To assess the impact of a novel feedback system on prescribing error rates and safety attitudes in a pediatric setting.
Main Methods:
- A Before and After study design was employed in a single inpatient pediatric unit.
- 26 pediatric medical staff participated, with baseline and 3-monthly reassessments of prescribing errors and safety attitudes.
- Feedback was provided via general and anonymous personalized posters and emails after each assessment.
Main Results:
- A statistically significant reduction in prescribing error rate from 8.8% at baseline to 1.8% at 3 months (P < 0.0001).
- Analysis of 205 medication orders revealed 3,280 opportunities for error.
- While patient safety attitudes showed improvement, the change was not statistically significant.
Conclusions:
- The pilot project demonstrated that an error feedback system can effectively reduce prescribing errors.
- The feedback technique is easily adoptable and scalable, suggesting potential for wider implementation.
- Further research is warranted to explore the broader applicability and long-term impact of this error feedback system.
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