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A specifically designed aminoglycoside prescription sheet: can it reduce risk in neonatal practice?
  1. L McGrory1,
  2. M Moohan2,
  3. F O'Neill3,
  4. M Stevenson4,
  5. G Ong5,
  6. C Mayes1
  1. 1Royal Jubilee Maternity Service, Belfast, UK
  2. 2Department of Pharmacy, Royal Hospitals, Belfast, UK
  3. 3Department of Pharmacy, Ulster Hospital, Dundonald, UK
  4. 4Queen's University, Belfast, UK
  5. 5Department of Microbiology, Royal Hospitals, Belfast, UK


Introduction Aminoglycosides are frequently associated with error in prescribing, administration and monitoring. The National Patient Safety Agency recommends using a care bundle to reduce error in neonatal gentamicin prescribing. This includes crossing out boxes on a standard medication prescription and administration record. This can cause confusion and in addition there are no specific areas for documentation of monitoring.

Methods In 2008, a specifically designed aminoglycoside prescribing sheet was introduced in a level 3 neonatal unit. Audits looking at appropriate dosing, drug level timing and response to abnormal levels were undertaken before and after introduction. The frequency of reported error prior to, and following introduction, was monitored through incident reporting.

Results Table 1 demonstrates a reduction in aminoglycoside errors of 80% following the introduction of the new prescribing sheet. This compares to a fall of 35% for non-aminoglycoside errors. We compared the rates of fall using a test of differential reduction (Fishers exact test, 2 sided p value), which approached significance (p=0.077).

Abstract PF.31 Table 1

Reported drug errors before and after the introduction of aminoglycoside prescription sheet

Conclusion An aminoglycoside prescribing sheet should be considered as part of a care bundle designed to reduce risk in Neonatal care.

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