Do not disturb! The impact of wearing red aprons on medication administration in PICU

Introduction and Aims: Medication errors cause significant morbidity and mortality to patients. The reported financial cost to the NHS annually is £1 billion, but could be up to £2.5 billion. Medication errors are one of the most frequently reported incidents on paediatric intensive care (PIC). Evidence of effective interventions that prevent medication errors is currently limited. However, implementing red apron use for medication administration aims to permit uninterrupted, dedicated time for nurses whilst preparing medications. The effectiveness that this intervention has on minimising medication administration errors in PIC is unknown. This project aimed to evaluate PIC medication administration errors after implementation of safe medication policy that included wearing red aprons. Methods: A retrospective review of PIC medication administration incidents reported during a six-month period before (November 2015-April 2016) and after (November 2016-April 2017) the introduction of the red apron intervention and the promotion of safe medication management. Type and frequency of incidents occurring pre and post intervention were compared. Results: Fifteen medication errors were reported before the intervention. This increased to 20 following. Interestingly, three types of errors that were reported before the intervention did not occur after, but five new error types were only reported after the intervention (figure 1). Four error types were reported at similar frequencies before and after the intervention. Discussion and conclusion: This study has provided valuable insight into medication administration error reporting. It appears that this intervention may not reduce errors in the short term, but may have an effect on culture and behaviour of medication error reporting. This includes raising awareness of medication errors amongst staff, and highlighting the importance of and support for safe administration of medications and reporting of errors. Further research will examine benefits of and barriers to implementing interventions aimed at improving medication safety for children in PIC.