Impact of a Process Change on Prevalence of Prescribed Unmeasurable Liquid Doses in a Neonatal Intensive Care Unit

Most prescribing through the electronic health record (EHR) in the NICU at St. Vincent Women's Hospital use a weight-based dosing calculator. Prescribers receive no alert if the resulting volume is unmeasurable. Study definition of measurable was a dose volume with a visible hash mark on an appropriately sized oral syringe. The primary objective was to compare the rate of unmeasurable oral liquid doses prescribed at discharge before and after implementation of educational process changes. Secondary objectives assessed patient and discharge medication characteristics in relation to the unmeasurable doses prescribed.

This study was a 2-phase retrospective analysis of patients discharged from the NICU between January 1 and June 30, 2016 (phase I), and between October 1, 2017, and March 31, 2018 (phase II). Patients were included in the analysis if they were discharged on at least 1 oral liquid medication, excluding vitamins. Demographic and discharge medication information was collected.

There were 58 patients discharged on a total of 118 oral liquid medications in phase I and 63 patients discharged on a total of 111 oral liquid medications in phase II. Following implementation of the process change, the percentage of unmeasurable discharge prescriptions decreased from 27 (23%) to 5 (4.5%) (p < 0.001).

The educational process change implemented in the NICU effectively reduced the rate of unmeasurable doses prescribed at discharge from 1 in 4 to 1 in 25. Additional system-level changes may result in further reductions.