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across all four criteria was achieved for 13% of patients attending the clinic from our baseline measure of 10%. Conclusion Introducing frequent, small change ideas through PDSA cycles allowed us quickly to identify our most successful interventions to address the frustration surrounding communication breakdown shared by all service users. This process will also be useful in the induction of new trainees managing the clinic. Targeted interventions resulted in a safer, more efficient service. Ongoing feedback continues to guide strategies for change as we strive towards improving the quality of post-discharge care for children and young people. Future work will focus on capturing patient experience and improving patientcentred outcomes.

AimsPrescribing medication is a common intervention and hence prescribing errors are not uncommon events. From the literature 13% of paediatric prescriptions contain errors1and recently it was estimated that 66 million of the 237 million prescription errors had potentially clinically significant outcomes.2This has been highlighted following a recent critical incident and, as part of the learning recommendations; a multidisciplinary team (MDT) approach was formed to improve departmental prescribing education. The aim was to reduce the number of prescribing errors, therefore reducing harm to patients, and improving patient care. This was achieved through the joint efforts of trainees and ward pharmacist by developing robust evidence-based teaching not only at induction but as rolling sessions throughout the year which, due to COVID-19 restrictions, was delivered virtually. In conjunction there was also a revision of the induction paediatric prescribing test, regular review of the number of prescribing error incidents and drug chart audits with cycle completion and implementation of changes. The teaching programme and audits were started in December 2020 and are on-going.MethodsFrom December 2020 to May 2021, audits were undertaken initially using the RCPCH Paediatric Prescribing Error tool.3We later revised the audit tool to also include the standards defined in our hospital inpatient prescribing policy. 30 random drug charts from across three paediatric inpatient wards were analysed every month with the aim to achieve greater than 90% in each standard (taking into account a baseline level of human error) and then to maintain this over time. To achieve this, learning from the audit was fed back to all members of the team via regular electronic and visual/verbal reminders and the teaching programme was amended to include troublesome topics. Adverse incidents were reviewed and teaching from this was also included in the teaching programme.ResultsSince December 2020, it took six months for the number of incidents due to prescribing errors to reduce from 14 in six months (December 2020-May 2021) to 10 in six months (June-November 2021). Audit results showed that since December 2020 we were scoring >90% in 3 out of the 10 domains. Three months into the teaching programme this improved to 4 out of 10 of the domains and at six months, 6 out of 10 domains. When re-audited with our revised audit tool, we achieved >90% initially in 10 out of 16 domains and then consistently maintained our standards across 11–12 out of 16 domains over a four-month period (October 2021-January 2022).ConclusionsThis project has shown that despite a global pandemic, a combination of innovation, education, technology, multidisciplinary skills and MDT working can implement and embed change to improve patient safety. When considering the bigger picture, we recognise this is a small part of the larger systemic processes that can influence medication errors and that with perseverance, we can aim to reduce the risk of adverse events due to medication errors and therefore provide the best care for our patients.ReferencesGhaleb MA, Barber N, Franklin BD,et al. The incidence and nature of prescribing and medication administration errors in paediatric inpatients.Arch Dis Child2010;95;113–118.Elliot RA, Camacho E, Jankovic D,et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England.BMJ Quality & Safety2021;30:96–105.RCPCH Paediatric Prescribing Error Audit Tool. https://qicentral.rcpch.ac.uk/medsiq/safe-prescribing/paediatric-prescribing-error-an-audit-tool/

To our knowledge this is the first published case of NP associated with COVID-19 in an individual with CF and the first associated with Nocardia infection. We suspect the combination of cystic fibrosis, COVID-19 pneumonitis and co-infection with Nocardia farcinia caused this young man’s NP and ultimately his untimely death. We hope this case will highlight individuals with CF of all ages are at risk of severe COVID-19 infection.