{
  "abstract": "Context The Newborn Care Unit (NCU) was the final ward in the trust to continue using paper prescribing, largely due to the complexity of neonatal prescribing. However, the Health Services Safety Investigation Body has highlighted the risks associated with operating paper and electronic systems in parallel, recommending this practice be minimised to reduce errors caused by multiple data entry and retrieval sources. This recommendation followed the death of a 75-year-old woman who received unintentional dual anticoagulant therapy due to concurrent paper and electronic prescribing. 1 To address this risk and support the trust’s Digital by Default strategy, a project was initiated to implement electronic prescribing within the NCU.A Band 7 specialist clinical pharmacist was appointed to develop a bespoke neonatal prescribing package that aligned with national best practice and met medicines governance requirements. A specialist digital neonatal nurse was recruited to provide nursing insight and support staff engagement. The wider project team included a neonatal consultant, neonatal registrars, the Electronic Prescribing and Medicines Administration (EPMA) Configuration Pharmacist, Lead Neonatal Pharmacist, Divisional Digital Lead, Digital Project Support Officers, and a dedicated project manager.To minimise the risk of mis-selection by clinicians outside newborn care, all neonatal prescriptions were built within prescribing care sets (‘PowerPlans’). The project team agreed a list of commonly prescribed medicines and high-frequency clinical scenarios, such as early-onset neonatal sepsis. Prescription templates were pre-populated with dosing and administration instructions using recognised resources, including the British National Formulary for Children, the South East London Paediatric Formulary and Medusa. Templates were filtered by postmenstrual age and weight to support safe prescribing and reduce selection errors.The electronic prescribing system went live in January 2025, with on-the-day support provided by the Trust Digital Team to manage and resolve issues in real time. Any issues identified were documented and followed up appropriately. Transcription of in-use paper drug charts to electronic prescriptions was undertaken by neonatal registrars and independently screened by trained neonatal pharmacists, with clinical oversight provided by the neonatal consultant on the day of go-live.A baseline audit of medicines-related errors in the NCU was conducted between June 2023 and February 2024. A follow-up audit is planned for July 2025 to evaluate the impact of electronic prescribing and to compare both the frequency and nature of medicines errors following implementation.Conclusions Pharmacists play a central role in the safe implementation of electronic prescribing in complex clinical areas, ensuring prescribing is safe, legal and clinically appropriate, governance requirements are met, and transcription during go-live is accurately verified. Digital teams must work closely with senior pharmacy leadership to secure protected pharmacist time and appropriate backfill, with additional pharmacy activity such as antimicrobial stewardship and governance explicitly considered during business planning.Clear project planning and dedicated project management support are essential to maintaining timelines. Ongoing medical and nursing engagement is critical to ensure prescribing sets reflect unit practice and to achieve full multidisciplinary buy-in. Close collaboration across all teams, supported by digital communication tools such as Microsoft Teams and shared documentation, underpins successful delivery.Reference Health Services Safety Investigations Body. Investigation report: Electronic prescribing and medicines administration systems and safe discharge. Published 24/10/2019. Available from: Investigation report: Electronic prescribing and medicines administration systems and safe discharge [Accessed 31/12/2025].",
  "authors": [
    {
      "affiliations": [
        "Oxford University Hospitals NHS Foundation Trust, UK"
      ],
      "name": "Stephen Mcinerney"
    },
    {
      "affiliations": [
        "Oxford University Hospitals NHS Foundation Trust, UK"
      ],
      "name": "Zoe Pallett"
    },
    {
      "affiliations": [
        "Oxford University Hospitals NHS Foundation Trust, UK"
      ],
      "name": "Mar Moreno"
    }
  ],
  "title": "P20 Clinical pharmacists’ insight into an ePMA rollout in newborn care",
  "uid": "09e9546b-75dd-56f9-805d-040f5e6701e0"
}