61 A quality improvement model for reducing prescription error at a children’s critical care retrieval service

Objectives We undertook a review of prescribing practice at CATS in order to identify interventions that could be implemented with the aim of reducing the frequency medication prescribing error. The design of the project will allow further assessment of the impact of these interventions through its Plan-Do-Study-Act approach. It will therefore provide a structure for ensuring a focus on quality during the implementation of future changes, such as moving to e-prescribing. Introduction The diverse operational environments CATS operate in create unique prescribing and medication-administration challenges. A prescribing accuracy audit is in place but the locally defined target of an error rate of Method We undertook quantitative review of the audit data and used thematic categorization to identify areas of prescribing that are frequently a source of error. Using a validated tool, we stratified the level of exposure to harm these pose to our patients. An electronic survey of medical and nursing practitioners in the Service was a qualitative exercise to understand the prescribing challenges they face. To explore the perceptions practitioners have of the causation of their own errors we reviewed responses to emails sent to inform them when one is identified. Results We identified three interventions that will be implemented, and their performance assessed through the methods above. These are an educational initiative, a drug chart adaption and an administrative process change