Introduction Staff on the renal ward in Ninewells Hospital have highlighted multiple prescribing errors affecting haemodialysis inpatients. Currently, they have two drug charts; one for the acute hospital admission and another for dialysis medications. Concerns were highlighted after duplicate antibiotic doses were administered out of hours, due to confusion surrounding two drug charts. The aim of this project was to reduce the number of drug chart errors by 50% departmentally, in keeping with the World Health Organisation ‘Patient Safety Challenge’.

Method Over three weeks the number of prescription chart errors were recorded, which included errors on personal details, allergies and antibiotic prescribing. Vancomycin and gentamicin are the most common antibiotics given on dialysis in NHS Tayside for line sepsis. Our proposed method of change introduced vancomycin and gentamicin stickers for the ward prescription chart, highlighting antibiotics given on dialysis. Medical staff were informed to utilise them in a departmental meeting. Thereafter, the prescription charts were re-audited over three weeks.

Results 86% of drug charts contained errors in week one. In weeks two and three, 100% and 50% of charts had discrepancies respectively. After the implementation, week one showed no errors on the drug charts. In weeks two and three, 20% and 60% of the charts showed mistakes respectively. There was a 66% overall decrease in drug chart errors. Nevertheless, week three showed an increase errors on charts.

Conclusion Although initial improvement was seen, the project ‘fizzled’ to an end as the junior doctors rotated. Due to the nature of four month rotations, it is difficult for positive change to be sustained. We consider this project highlights the importance of leadership and why good initiatives can fail without it. To establish long-term change, we must involve a member of staff with a permanent position in that environment, a leader.