Designing an electronic prescribing and medicines administration system in a paediatric setting

Electronic prescribing and medicines administration (ePMA) systems have been widely adopted in healthcare settings to enhance the accuracy and efficiency of medication prescribing and administration; however, the unique requirements of paediatric patients present significant challenges to these systems. Owing to their varying weights, clinical conditions and developmental stages, paediatric patients require individualised drug dosing, and off-label and unlicensed medicines formulations. These specific needs can increase the risk of prescribing errors for this vulnerable population.

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This article, which is part one of a two-part series, discusses the benefits of ePMA systems and what should be considered when designing or updating a system. Implementation considerations will be discussed in part two.

How ePMA systems can improve paediatric care

Paediatric prescribing errors are a significant concern, with figures suggesting that they affect around 13% of UK prescriptions, often resulting in severe consequences^​1,2​. These errors are up to three times more likely to cause harm in children than in adults^​1,3,4​. This highlights the critical need for targeted interventions and improved safety measures in paediatric medication management, such as ePMA systems^​5​.

Research shows encouraging results when ePMA is introduced in paediatric settings, particularly with a reduction in prescribing errors by ensuring clarity, accessibility and completeness of prescriptions^​6​. It is also recognised that the benefits of ePMA to prevent harmful prescribing errors depends on how the system is set up and optimised^​6​.

Although ePMA systems have the potential to enhance prescribing safety, dosing errors remain a significant issue^​7​. For example, the Healthcare Safety Investigation Branch has identified multiple incidents involving ePMA systems in paediatrics^​8,9​. The varied outcomes from adopting e-prescribing systems are likely owing to differences in the systems used and how they were implemented. The effective implementation and optimisation of ePMA systems are essential, yet many systems lack basic paediatric-specific functionalities, such as weight-based dosing^​10​. Although reports on ePMA-related errors in paediatrics are limited, common problems include incomplete prescriptions, incorrect dosages and missing weight records^​11,12​. ePMA systems can also introduce new issues, such as alert fatigue from frequent warnings and automation bias^​6,10​. It is crucial to tailor ePMA systems to the specific needs of paediatrics, provide adequate support to prescribers and set realistic expectations of each system’s functionality. 

The functionalities described below will be necessary for most paediatric wards, but — as mentioned — a system can and should be matched to an individual trust’s needs. The advice given in this article applies whether implementing an entirely new system, optimising a system already in place, or converting a system designed for adult patients to one for paediatrics.

System functionalities

ePMA system functionalities must be carefully considered and configured to address the needs of paediatric patients.

• Clinical decision support tools: The system should be able to provide alerts to users, especially when doses exceed maximum recommended amounts. This feature is also important for managing conditions such as obesity, renal insufficiency or ketogenic diets, in which drugs, formulations and dosing may significantly vary;
• Dose units display: The system should be capable of displaying dose per kg, ensuring clarity and precision in dosing;
• Dose calculations and dose rounding: The system should be capable of calculating doses based on weight to ensure accurate, tailored dosing. Additionally, it should allow for dose rounding^​13​;
• Reference doses and indication display: The system should display reference doses within the system to highlight the intended prescribed dose to other ePMA users and confirm that the total dose is as intended and meets indication prescribing;
• Mandatory weight checking: Given that paediatric doses are predominantly based on patient weight, the system should require mandatory weight entry, either actual or estimated weight, before prescription initiates. Additionally, the system should accommodate and document various types of working weights, such as adjusted body weight or ideal body weight, which are crucial when adjusting doses for neonates, people with obesity and those requiring specialist care;
• Double witnessing for drug administrations: To facilitate second checking, the system should be able to set double witnessing for drug administration at drug, user or ward level;
• Parent, carer or self-administration: The system should support workflows that allow for parent, carer or self-administration of medications where appropriate^​14,15​;
• Short-term or home leave: There should be a clear process within the system to manage medications for patients on short-term leave or home leave, ensuring continuity of care and adequate documentation;
• Free-text entries for drug administration methods: Allow free-text entries for off-label drug administration methods; for example, instructions on how to manipulate a drug dosage form (e.g. 3mg daily from a 10mg tablet: ‘crush a 10mg tablet, dissolve in 10mL of water and give 3mL of the resulting solution’)^​16​. This allows flexibility while ensuring all necessary details are documented.

Drug build

Careful attention must be given to the drug build when developing an ePMA system for paediatric patients. This involves creating a comprehensive, detailed drug database that meets all paediatric requirements with appropriate dosage forms, strengths, routes and dose units. Weight-based, age-specific and indication-specific dosing guidelines should be integrated to ensure accurate dosage calculations. The drug build should also incorporate a list of dose units that are suitable for both adult and paediatric settings to avoid confusion and errors. Detailed information on paediatric formulations, such as liquid preparations and dispersible tablets, is essential.

• Paediatric formulary drugs: It may be necessary to modify existing drug files designed for adult patients to meet paediatric needs. This includes incorporating more liquid preparations and dispersible tablets to cater for smaller doses used in young age groups. Collaboration with the paediatric team is essential to ensure all specific requirements are met;
• Multiple dose units: The system should support displaying and switching between multiple dose units during prescribing to accommodate different dosages across different age groups. For example, folic acid might be prescribed in milligrams for older children and adults but in micrograms for neonates, and phosphate effervescent tablets might be dosed in millimoles per kg for paediatrics and as a number of tablets for adults^​17,18​;
• Default dosage limits: Implementing default dosage limits within the system can help prevent both overdosing and underdosing, enhancing patient safety. Ideally, the system should accommodate the maximum doses for neonates and children, in addition to adult ceiling doses;
• Wider range of administration routes: Consider enabling a wide range of administration routes. Certain IV medications, for example fentanyl, may be administered intranasally to paediatric patients. Checking guidelines and the summary of product characteristics are essential when setting the administration routes for a drug^​19​;
• Placeholders for non-formulary and non-stock drugs: Paediatric patients may receive medications from paediatric specialist centres that are non-formulary and are not stocked in your trust. If the medicine is a long-term treatment for the patient, arrangements must be made to ensure continuity of supply^​20​. Patients should also continue to take their own medications, or get medications supplied with the same strengths and formulations, during their hospital stay. Processes must be in place to ensure that these drugs can be managed in the system. Having placeholders for non-formulary drugs in the system ensures that all medications can be prescribed and administered within the system; however, processes should be established to manage these drug files to prevent regular prescribing of non-formulary drugs;
• Clear display of the concentration of liquid medications: Many liquid medications are available in various concentrations, posing a significant risk of medication errors. To mitigate this risk, the system should avoid allowing medications to be prescribed only in millilitres unless indicated in the BNF, such as co-amoxiclav. If prescribing in millilitres is unavoidable, the system must clearly display the concentration of the liquid medication to ensure accurate dosing and enhance patient safety;
• Discharge medication display: Careful consideration is required regarding the display of drug information on a patient discharge summary to ensure clarity and continuity of medicines in primary care. Consider participating in medicines optimisation schemes, such as the NHS Discharge Medicines Service;
• Impact on drug ordering and dispensing: The drug build must be designed to streamline drug ordering, procurement and dispensing processes, supporting closed-loop medication management and minimising errors and delays.

Protocols

Protocols in an electronic system for healthcare refers to the standardised procedures or prescribing guidelines that are embedded within the system to ensure consistent and evidence-based care delivery. Establishing robust protocols is vital for the safe and effective implementation of ePMA systems in paediatric care. These protocols should outline clear guidelines for standard treatment for both common and specific paediatric conditions, streamlining the prescribing and administration process and reducing variability. 

• Default dosage limits: Set specific dosage limits for specific conditions to help prevent dosing errors and ensure patient safety;
• Age-range or weight-range limits: Protocols should be able to incorporate age-range or weight-range limits to guide prescribers in selecting appropriate doses and tailoring to the specific needs of paediatric patients;
• Flexible administration routes: Certain protocol functionalities allow nurses to select different routes or formulations for the same medication within a protocol; for example, a protocol for PO/IV ondansetron may offer options for tablets, liquid or IV injection. Paediatric wards may need many of these protocols to obtain flexibility to accommodate the varying needs within medication administration in children;
• Dose titration: Many paediatric treatments require dose titration, such as steroids and anticonvulsants. The protocol should enable prescribers to easily prescribe dose titration, supporting personalised treatment plans and ensuring that the titration information is displaying in the correct order on the discharge summary.

IV infusions

IV infusion medications present challenges in paediatric care owing to the complexities of infusion-related parameters. National standards for IV infusions in children must be considered when building and configuring infusion protocols. 

• Prescribing units: The system should allow infusions to be prescribed in different units, such as mg/kg/hour or microgram/kg/min, to accommodate various medication requirements;
• Incorporate weight in the build: The infusion module must be capable of incorporating weight into the calculations for infusion rate and dose rate to ensure accurate dosing;
• Infusion rates: The system should enable setting dose rates in microgram/kg/min while calculating infusion rates in mL/hour, not mL/min. This flexibility is necessary for building accurate infusion. For example, to administer a dose of 0.5 micrograms/kg/min of adrenaline to a neonate, the system should calculate the infusion rate in mL/hour^​21​;
• Default infusion rate and duration: The ability to set default infusion rates and infusion duration can reduce the risk of side effects. For instance, vancomycin intermittent IV infusion should be administered at a maximum rate of 10 mg/min to minimise the risk of severe reactions^​22​;
• Flexible diluent options: For paediatric patients, especially neonates, drug infusions may need to be diluted in glucose. If the system does not allow diluent selection, it should support building multiple infusion options with different diluents;
• Minimum and maximum ranges: The system should support setting minimum and maximum infusion ranges in mL/kg/hour or microgram/kg/min to ensure safe administration, particularly for neonates;
• Dose concentration limits: The system should allow setting both maximum and minimum dose concentrations to prevent potential tissue irritation or extravasation and to ensure the stability of the infusion;
• Infusion expiry dates: Setting expiry dates for infusions and alerting administrators to change the infusion, such as the drugs made in aseptic with short expiry dates, is crucial for maintaining patient safety;
• Infusion prescribing and administration process: The infusion functionalities often require new process adaptations; for example, nurses may need to document the end of infusion and bag changes when recording the dose. It is advisable to set a default duration for continuous IV maintenance fluids, so these infusions will conclude automatically. If a default duration is not set, prescribers will need to be trained on how to deprescribe fluids that are no longer indicated. This ensures that unnecessary infusions are promptly discontinued and avoids confusion;
• Infusion compatibility documentation: Consider carefully how to display infusion compatibility information, such as the compatibility of drugs with total parenteral nutrition, to ensure safe and effective administration.

Conclusion

ePMA systems can provide considerable benefits to medication management in a paediatric setting. When designing a system, it’s important to consider the needs of paediatric patients and the individual organisation. Part two of this series will focus on considerations at implementation.