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The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into the risks involved in prescribing, dispensing and administering medicines to children.
The investigation was triggered after the HSIB, which conducts independent investigations of patient safety concerns in NHS-funded care across England, was notified of an incident including a child aged four years, who, after being diagnosed with a blood clot in her leg following a surgical procedure, received ten times the intended dose of anticoagulant on five separate occasions, over three days.
This, the HSIB said, was owing to errors that occurred during the prescription, dispensing and administration processes.
The errors resulted in the child being admitted to the paediatric intensive care unit, with evidence of a bleed in her brain, where she stayed for three months until she was discharged with an ongoing care plan.
The HSIB said that studies showed that prescribing errors were the most frequent type of medication error in children’s inpatient settings.
The investigation will look at this and other incidents to examine the role of multidisciplinary teamworking and checking in medication errors, as well as considering the risks associated with the implementation of electronic prescribing and medication administration (ePMA) systems in clinical areas using weight-based paediatric prescribing.
“‘Wrong dose’ errors are a particular risk in children’s wards,” said Alice Oborne, consultant pharmacist in safe medication practice and medicines safety officer at Guy’s and St Thomas’ NHS Foundation Trust.
“Unlike adults, paediatric inpatients can vary 10-fold in their body weight: one might have a 3-month-old in the same ward as a mature 17-year-old, who could be 80kg, making it less easy to recognise an incorrect prescription.”
Oborne said that the safety of an ePMA system depended on how it has been configured from the outset, and the extent to which it had been configured to prescribe freehand or have pre-built prescriptions.
“The prescribing systems in the UK differ,” she said. “Thus, the design of the ePMA system is key to preventing dosing errors at the point of prescribing.
“Other steps can reduce risk of error; for example, readily available decision support in the ePMA or organisation’s intranet to indicate usual doses for body weights. These help to reduce some human factors which contribute to error, such as fatigue or interruption.”
Oborne explained that safe medicines use was also facilitated by a strong culture of teamworking, where staff feel empowered to speak up when they think things are not as they should be; for example, excessive workload.
“Appropriately trained pharmacists can act as a safety net to identify and correct prescribing errors,” she added.
As part of its final investigation report, the HSIB will make safety recommendations to the appropriate national bodies to improve patient safety.
