Medication audit and feedback by a clinical pharmacist decrease medication errors at the PICU: An interrupted time series analysis

• Published in: Health science reports Vol. 1; no. 3; pp. e23 - n/a
• Main Authors: Maaskant, Jolanda M., Tio, Marieke A., Hest, Reinier M., Vermeulen, Hester, Geukers, Vincent G.M.
• Format: Journal Article
• Language: English
• Published: United States John Wiley & Sons, Inc 01.03.2018; John Wiley and Sons Inc
• Subjects: Audits; Data collection; Drug administration; Feedback; harm; Intensive care; Intervention; ITS; Medical errors; medication error; multifaceted intervention; Nursing; Patients; Pediatrics; pharmacist; PICU; Prescriptions; Researchers; Time series; pharmacist; multifaceted intervention; ITS; harm; PICU; medication error
• ISSN: 2398-8835; 2398-8835
• DOI: 10.1002/hsr2.23

Objective Medication errors (MEs) are one of the most frequently occurring types of adverse events in hospitalized patients and potentially more harmful in children than in adults. To increase medication safety, we studied the effect of structured medication audit and feedback by a clinical pharmacist as part of the multidisciplinary team, on MEs in critically ill children. Method We performed an interrupted time series analysis with 6 preintervention and 6 postintervention data collection points, in a tertiary pediatric intensive care unit. We included intensive care patients admitted during July to December 2013 (preintervention) and July to December 2014 (postintervention). The primary endpoint was the prevalence of MEs per 100 prescriptions. We reviewed the clinical records of the patients and the incident reporting system for MEs. If an ME was suspected, a pediatrician‐intensivist and a clinical pharmacist determined causality and preventability. They classified MEs as harmful according to the National Coordinating Council for Medication Error Reporting and Prevention categories. Results We included 254 patients in the preintervention period and 230 patients in the postintervention period. We identified 153 MEs in the preintervention period, corresponding with 2.27 per 100 prescriptions, and 90 MEs in the postintervention period, corresponding with 1.71 per 100 prescriptions. Autoregressive integrated moving average analyses revealed a significant change in slopes between the preintervention and postintervention periods (β = −.21; 95% CI, −0.41 to −0.02; P = .04). We did not observe a significant decrease immediately after the start of the intervention (β = −.61; 95% CI, −1.31 to 0.08; P = .07). Conclusion The implementation of a structured medication audit, followed by feedback by a clinical pharmacist as part of the multidisciplinary team, resulted in a significant reduction of MEs in a tertiary pediatric intensive care unit. Our study shows that the implementation of structured medication audit, followed by timely feedback by a clinical pharmacist as part of the multidisciplinary team, resulted in a significant reduction of medication errors in a tertiary pediatric intensive care unit. We observed a nonsignificant decrease in medication‐related patient harm. The proactive role of the clinical pharmacist resulted in recommendations with a high acceptance rate.