Drug prescription before and after implementation of a CPOE system on the Paediatric Intensive Care Unit: a quality improvement study.

Abstract

Study aims: Paediatric drug prescription is complex, especially in the paediatric intensive care unit (PICU), where errors may be particularly harmful due to frequent use of high-risk medications. The widespread use of electronic prescriptions is a national goal in Switzerland to improve the quality of prescriptions and reduce medication errors.With this background, this study assessed the quality of drug prescriptions before and after implementation of electronic prescriptions on the PICU of a tertiary Paediatric University Hospital.

Methods: This quality improvement study was conducted during implementation of a Computerised Physician Order Entry (CPOE) on the PICU of a Swiss paediatric university hospital. A paediatric dosing standard with an integrated dose calculator was incorporated as a default clinical decision support tool. Manual prescriptions before (April-September 2022) and electronic prescriptions after (September-December 2022) CPOE implementation were assessed for (1) dose calculation errors (primary outcome), (2) eight quality criteria defining a formally complete prescription according to the internal medication standard and (3) dose compatibility with the paediatric dosing standard (secondary outcomes).

Results: A total of 767 (348 manual, 419 electronic) prescriptions from 107 patients (53 before and 54 after CPOE implementation) were collected. No dose calculation errors were detected in electronic prescriptions versus three in manual prescriptions (0.8%, p = 0.09) from three patients (5.6%). A total of 16 (5%) manual prescriptions were formally complete versus 197 (47%) of electronic prescriptions following CPOE implementation (p <0.001) according to the internal medication standard. The most frequently missing elements in manual prescriptions were total daily dose (64%), pharmaceutical form (58%) or brand name (32%), versus total daily dose (38%), pharmaceutical form (25%) or strength (2%) in electronic prescriptions. Dosing was consistent with the paediatric dosing standard in 235 (68%) of manual prescriptions and 313 (75%) of electronic prescriptions (p = 0.035).

Conclusion: The findings of this quality study provide arguments for the potential of CPOE with integrated paediatric dose selection and calculation to improve paediatric medication safety on PICU, in particular by increasing completeness and standardisation of drug prescriptions. Nevertheless, only 47% of electronic prescriptions were formally complete, and new potential sources of prescribing errors linked to increased complexity of drug prescriptions were seen. This underlines the need for close interdisciplinary monitoring of electronic prescription systems, additional training time for users, and flexibility for adjustments based on user experience with corresponding dedicated resources.