BMJ Qual Saf 22:256-262 doi:10.1136/bmjqs-2012-001089
  • Quality improvement report

Personalised performance feedback reduces narcotic prescription errors in a NICU

Open Access
  1. John Chuo4,5
  1. 1Department of Pediatrics, Nemours Neonatology, AI duPont Hospital for Children, Wilmington, Delaware, USA
  2. 2Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
  3. 3School of Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  4. 4Department of Neonatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5Department of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
  1. Correspondence to Dr John Chuo, University of Pennsylvania, Neonatal Quality Officer, Children's Hospital of Philadelphia, 2NW2428 Civic Center Blvd, Philadelphia, PA 19104, USA; chuoj{at}
  • Received 18 April 2012
  • Revised 9 August 2012
  • Accepted 29 August 2012
  • Published Online First 4 October 2012


Objective Neonates are at high risk for significant morbidity and mortality from medication prescribing errors. Despite general awareness of these risks, mistakes continue to happen. Alerts in computerised physician order entry intended to help prescribers avoid errors have not been effective enough. This improvement project delivered feedback of prescribing errors to prescribers in the neonatal intensive care unit (NICU), and measured the impact on medication error frequency.

Methods A front-line multidisciplinary team doing multiple Plan Do Study Act cycles developed a system to communicate prescribing errors directly to providers every 2 weeks in the NICU. The primary outcome measure was number of days between medication prescribing errors with particular focus on antibiotic and narcotic errors.

Results A T-control chart showed that the number of days between narcotic prescribing errors rose from 3.94 to 22.63 days after the intervention, an 83% improvement. No effect in the number of days between antibiotic prescribing errors during the same period was found.

Conclusions An effective system to communicate mistakes can reduce some types of prescribing errors.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: and

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