Assessing the impact of weight documentation on adverse drug events: a quality improvement initiative to reduce prescribing errors and improve patient safety

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H Damirji, A Scott and J Kalindjian

Guys and St Thomas’ NHS Trust, UK

: J Nurs Patient Care

Abstract

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Aim: Prescribing errors are common in the NHS, with evidence showing causation is complex and often multifactorial. Our objective was to evaluate the impact of a single variable, weight documentation, on the incidence of prescribing errors and implement a change to reduce such errors thereby improving patient safety.

Method: Cardiology inpatients (n=54) on 16/06/17 at a Central London hospital were included in this audit. Data was gathered from electronic records (E-noting) and from an electronic prescribing system (MedChart). Patient weight discrepancies between the two systems were analyzed and the impact on weight-related medication was assessed. Recommended changes were implemented following multidisciplinary meetings between nurses, doctors and pharmacists, by a poster campaign on relevant wards and presentation at the local departmental meeting. Following implementation of recommendations, a re-audit was completed with the same inclusion criteria (n=44) on 26/06/17 and the incidence of weight-related prescribing errors reviewed.

Results: Post-intervention the percentage of patients with weight documented on MedChart improved from 76% to 98%, with a 10% reduction in weight discrepancy between the two systems, E-noting and MedChart. Initial audit data showed 4% of patients had a prescribing error related to incorrect dosing of weight-based medications; these errors all involved inappropriate anticoagulation with low molecular weight heparin. Following implementation of recommendations 0% of patients had a weight related prescribing error.

Conclusion: Accurate weight recordings are vital to reduce the incidence of prescribing errors in patients on weight-dosed medications. This is emphasized in cardiology where inpatient weight frequently fluctuates secondary to both congestive cardiac failure and administration of diuretics. In this population particularly, precise weightbased prescribing of anti-coagulants is imperative. Our findings show that updating weight documentation onto the electronic prescribing system MedChart reduced the frequency of prescribing errors to 0% thereby improving patient safety.

Biography

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