RT Journal Article SR Electronic T1 Personalised performance feedback reduces narcotic prescription errors in a NICU JF BMJ Quality & Safety JO BMJ Qual Saf FD BMJ Publishing Group Ltd SP 256 OP 262 DO 10.1136/bmjqs-2012-001089 VO 22 IS 3 A1 Kevin M Sullivan A1 Sanghee Suh A1 Heather Monk A1 John Chuo YR 2013 UL http://qualitysafety.bmj.com/content/22/3/256.abstract 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.