PT - JOURNAL ARTICLE AU - Kevin M Sullivan AU - Sanghee Suh AU - Heather Monk AU - John Chuo TI - Personalised performance feedback reduces narcotic prescription errors in a NICU AID - 10.1136/bmjqs-2012-001089 DP - 2013 Mar 01 TA - BMJ Quality & Safety PG - 256--262 VI - 22 IP - 3 4099 - http://qualitysafety.bmj.com/content/22/3/256.short 4100 - http://qualitysafety.bmj.com/content/22/3/256.full SO - BMJ Qual Saf2013 Mar 01; 22 AB - 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.