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12 Reducing prescribing errors amongst junior doctors at the beginning of their during hospice rotations- a quality improvement project (QIP)
  1. Isobel Morton
  1. Manorlands Hospice, Sue Ryder


Background It is documented within the literature that when transitioning between different forms of prescribing, errors are more likely to occur. This is especially pertinent within Hospice Medicine as many Hospices differ in their prescribing practices to those at Hospitals. This has been noted at Manorlands Hospice, whereby paper prescribing is used, with the local hospital having transitioned to electronic prescribing.

It had been noted amongst staff that a peak in prescribing errors occurred at the beginning of each rotation of new Junior Doctors, many of which resulted in a Datix (incident report). This QIP used the ‘PDSA’ methodology to look into this phenomenon and try and reduce it.

Methods Datix information regarding prescribing errors that occurred between December 2013 and April 2018 was collected. From this data and conversations with staff, a ‘Safe Prescribing Guide’ (SPG) was created that was given to new Doctors during their induction. This included information about how to reduce drug errors, and highlighted risky areas.

Results 42 Datix were identified as having occurred within the first month of a new rotation. This resulted in an average of 3 Datix per new rotation. The most common drug errors were due to the prescription of incorrect doses and the omission of medications.

Following the introduction of the SPG in August 2018, no drug errors occurred within the first month of the new Junior Doctors rotation.

Conclusion This QIP has highlighted the importance in recognising the new challenges faced by Junior Doctors due to the rapidly changing clinical environment as a consequence of new technologies. Following the implementation of the SPG drug errors have been reduced. However this could be due to a number of factors and ongoing data collection is required to identify the trend. The SPG has now been disseminated to Sue Ryder Hospices nationally.

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