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Pictorial prescribing reduces fentanyl drug administration errors: a simulated controlled study
  1. Stephen W Booth1,
  2. Maria Gloag2,
  3. Sara Kinna2,
  4. Andrew Bell2,
  5. Joanna L C Wheble2 and
  6. Daniel W Wheeler1,2
  1. 1Division of Anaesthesia, University of Cambridge, Cambridge, UK
  2. 2Department of Anaesthetics, Addenbrooke's Hospital, Cambridge, UK
  1. Correspondence to Dr Daniel W Wheeler, Division of Anaesthesia, University of Cambridge, Box 93, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK; dan.wheeler{at}gmail.com

Abstract

Objectives Transmucosal fentanyl is used to treat transient exacerbations of cancer pain. Several immediate release products are available, presented as intranasal sprays, sublingual and buccal tablets, or lozenges. These are not interchangeable, creating potential for medication errors. We compared the incidence of medication errors in a simulated scenario using handwritten drug charts and charts labelled with preprinted self-adhesive stickers with full pictorial fentanyl prescriptions.

Methods 54 nurses were shown 5 handwritten drug charts and 5 with self-adhesive pictorial labels. Nurses indicated which preparation and dose they would administer from boxes of Instanyl, Abstral, Effentora and Actiq (Nycomed, ProStrakan, Cephalon and Teva, respectively). We measured the frequency of drug administration errors and asked them to rate the prescriptions for clarity on four-point Likert items.

Results The use of pictorial self-adhesive prescriptions significantly reduced errors in choice of preparation, from 20 with traditional handwritten charts to 6 with self-adhesive labels (OR 3.52, 95% CI 1.39 to 8.90, p=0.006), but the incidence of dose error was not significantly different (OR 1.47, 95% CI 0.80 to 2.70, p=0.281). Analysis of Likert items showed using pictorial printed labels significantly improved nurses’ understanding of choice of preparation, dose and maximum four hourly dose (p<0.0001, p=0.006 and p=0.028, respectively).

Conclusions The use of pictorial prescribing appears to be a promising strategy that could reduce medication errors in choice of fentanyl preparations. There may be a wider use for pictorial prescribing where non-interchangeable preparations of the same drug exist.

  • Drug administration
  • Pain
  • Received 23 March 2015.
  • Revision received 6 May 2015.
  • Accepted 23 June 2015.

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  • Received 23 March 2015.
  • Revision received 6 May 2015.
  • Accepted 23 June 2015.
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