{
  "abstract": "Problem Medication errors are the most common type of clinical incident reported in paediatric hospitals. Potential harm is significant. 1 In March 2023, the Medication Safety and Quality Improvement teams of a specialist paediatric hospital joined forces to develop effective strategies to: a) Produce robust data capture mechanisms to inform and monitor improvement plans b) Engage key stakeholders across the organisation in identifying, planning and undertaking improvement plans c) Provide mechanisms for feedback from those involved in medication errors d) Lead strategic projects to reduce risk of medication errors e) Develop effective national links with key stakeholders in paediatric medication safetyWith the introduction of a new incident reporting system in May 2023, the medication safety team designed and built interactive, live incident dashboards to track medication incident trends across divisions, specialties and wards. These enabled tracking of processes, drugs, types of error, levels of harm, key targets and other desired fields on incident reports. Prompt identification of areas of improvement between areas became routine practice and allowed data driven projects to be continuously developed. These included strategies to reduce interruptions in the prescribing and administration processes; improvements to dispensing processes; consolidation of widely used guidelines to improve accessibility and tailored training sessions for wards.Multidisciplinary medication safety collaboratives were designed and facilitated quarterly with support from the quality improvement team. These created a forum for area managers, practice educators, consultants and other invested members of the multidisciplinary team to share successes and ongoing medication safety improvement work in their areas. We share current updates of trends for cross-divisional learning and have now successfully hosted eight collaboratives with increasing attendance and engagement. Feedback from these has been positive and has also strengthened our communication pathways across the Trust.Staff feedback mechanisms were improved in line with the new Patient Safety Incident Response Framework to provide more support to managers as well as those involved in incidents.2 Electronic feedback forms are available for prescribers and nurses to provide feedback on contributory factors and systemic improvements to prevent future similar incidents. These responses are reviewed and actioned bi-monthly by the medication safety committee.Our medication safety team engages with regional and national networks including the paediatric medication safety officers network, which was developed in late 2022 by our Principal Medication Safety Consultant Pharmacist.Conclusion In April 2025, we achieved the following as a result of the collective efforts of the described strategies and stakeholder engagement: a) Reduced the number of medication incidents resulting in harm by 25%.b) Increased the percentage of near miss reporting across the Trust.c) Reduced the number of medication errors resulting in moderate harm to zero.d) Reduced the number of administration and prescribing incidents reaching a patient by 10%.e) Reduced the number of 10-fold medication errors by 15%.Access to manipulate and effectively analyse live, detailed incident data allows for focused quality improvement projects. This needs to be combined with sustained engagement from key stakeholders on a Trust wide level to drive improvements in medication safety.References Conn R, Fox A, Carrington A, et al. The Pharmaceutical Journal. 2021;306(7946). doi:10.1211/PJ.2021.1.42997.NHS England. Patient Safety Incident Response Framework [Internet]. 2024 Jul 23 [cited 2025 Aug 12]. Available from: https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/",
  "authors": [
    {
      "affiliations": [
        "Alder Hey Children’s Hospital NHS Foundation Trust, UK"
      ],
      "name": "Georgina McIntosh"
    },
    {
      "affiliations": [
        "Alder Hey Children’s Hospital NHS Foundation Trust, UK"
      ],
      "name": "Andrea Gill"
    },
    {
      "affiliations": [
        "Alder Hey Children’s Hospital NHS Foundation Trust, UK"
      ],
      "name": "Helen Baldwin"
    },
    {
      "affiliations": [
        "Alder Hey Children’s Hospital NHS Foundation Trust, UK"
      ],
      "name": "Bethany Richards"
    }
  ],
  "title": "P47 Utilising data and maintaining engagement to drive medication safety improvements in paediatrics",
  "uid": "d0649137-8f92-5a48-9812-85758cfcfd3d"
}