Safe Prescribing Case Study

Safe Prescribing Tyler was treated at 3 days of age for possible group B strep sepsis.  He was admitted from home to the general paediatric ward on a busy Sunday  night.  He was commenced on benzylpenicillin and gentamicin which is trust policy but the admitting doctors were unclear about the gentamicin dose.  In the morning the ward pharmacists identified a dosage calculation error that meant that Tyler had received a significant overdose of gentamicin with potential hearing loss as a consequence.  This was raised at a subsequent clinical governance meeting and identified as a recurrent problem.  As a result a working group of a junior doctor, pharmacist, and paediatric consultant designed a gentamicin prescribing calculator that could be accessed via the Trust intranet.  Ongoing data collection showed a significant fall in gentamicin prescribing errors and a reduction in patient harm from such errors.