G87 It’s a ‘druggle’: reducing drug errors and disseminating learning

Aims Our aim was to improve team awareness of medication errors on the general paediatric ward by June 2019. We hoped that this would: Improve safe prescribing; Reduce medication errors. Methods An audit revealed frequent and serious administration and prescribing errors on the general paediatric ward. Over a half were administration errors and a third were prescribing errors. Other trusts have implemented discussions around drug errors known as a ‘Druggle’. We have replicated the idea but adapted it to make it relevant to our trust. A multipronged, multidisciplinary intervention was planned using a PDSA approach which included: implementing a weekly Druggle, to be attended by the multidisciplinary team (MDT). The purpose of our Druggle is to review all the drug errors and near misses from the previous week with discussion and action points on how to reduce the likelihood of the errors recurring; dissemination of learning points from the Druggle; restructuring the paediatric prescribing induction. Outcome measures: weekly attendance at the druggle; dissemination of learning; restructure of the paediatric prescribing induction; total number of drug errors (as recorded on Datix). Results Our run chart demonstrates that a steady increase in attendance at the Druggle, now maintained at 100% for a number of months. There was a temporary fall in attendance when there was a change in the staff leading the project, which resolved with new leadership. Learning is disseminated at nursing huddles and highlights in the monthly governance letter. The paediatric prescribing induction has been restructured to test basic paediatric prescribing skills and prescriptions to be successfully completed on the electronic prescribing system. There has been a sustained reduction in drug errors over time with an overall 24% reduction in administration and prescribing drug errors comparing the 8 weeks pre and post-intervention. Conclusions Drug errors are trending downwards with nearly a quarter reduction in errors. This project is particularly valuable as the education is ongoing and weekly action taken. There were several challenges and areas for learning: finding a convenient location and time; MDT involvement in planning and implementation; encouraging pharmacy to take ownership and the need for a project lead to ensure sustainability.