780 - Reducing Prescribing Errors for Common Outpatient Antibiotics

Poster Number: 780
Publication Number: 780.148

Eleanor H. Lee, Advocate Children's Hospital - Oak Lawn, Elmhurst, IL, United States; Sreya Patel, Advocate Children's Hospital - Oak Lawn, Chicago, IL, United States; Emily Keller, Advocate Children's Hospital - Oak Lawn, Oak Lawn, IL, United States; Shea Gallus, Advocate Children's Hospital - Oak Lawn, Oak Lawn, IL, United States

Background: Medication errors are some of the most common types of medical errors, causing patient safety issues and increased healthcare costs. Pediatric medicine poses a unique challenge due to weight-based dosing, relatively high turnover rate, and limited medication adherence requiring tailored formulations.

Objective: This quality improvement study aims to identify the overall error rate and the most common modifiable types of discharge amoxicillin-clavulanate prescription errors for pediatric patients.

Design/Methods: Using Epic Slicer Dicer tool, we retrospectively identified patients who were discharged with amoxicillin-clavulanate from the pediatric inpatient units, PICU, and pediatric ED at Advocate Children’s Hospital in Oak Lawn between 7/1/2021-6/30/2022. Information was collected and stored in REDCap. The error occurrence was compared between formulation type, location of patient at discharge, and prescriber’s training level. A prescription was counted as an error if it deviated from the standard dose (40-45 mg/kg/day) or high dose (80-90 mg/kg/day) with a maximum of 2 grams of amoxicillin per day. Frequency errors were defined as prescriptions that were not dosed twice a day. Dosing volumes that were not a whole number or did not end in 0.5 were defined as “impractical errors.”

Results: 883 encounters met our criteria. 240 prescriptions were duplications, most frequently from order revisions. Out of 643, a total of 363 errors were identified. There were 285 impractical errors, 127 dosage errors, and 25 frequency errors. The overall error rate between different locations of discharge was similar: 59.52% in the ED, 62.5% in the PICU, 56.6% in one of the two pediatric inpatient floors, and 49% in the other. When grouped by the level of training, the highest rate of error was with nurse practitioners (65.93%), followed by family and emergency medicine residents (56.52%), attending physicians (56.42%), and pediatric residents (ranging from 46.88 and 54.9% based on the level of training).

Conclusion(s): Over half of the prescriptions reviewed in this study were found to have at least one type of error. Impractical errors were the most common type, regardless of the discharge location or the prescriber’s level of training. Statistical analysis will be performed to determine significant difference. PDSA cycle 1 intervention was started based on these findings, which includes institutionalized pharmacist review on discharge antibiotics. Results from cycle 1 intervention is under review.