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Caron Heyes highlights alarming statistics of medication errors involving children

Caron Heyes
The government's Healthcare Safety Investigation Branch (HSIB) recently opened a national investigation into weight-based medication errors in children. The investigation was prompted by a combination of the catastrophic injuries caused to a four-year-old following 10x the normal dose of anticoagulants being given to him five times over three days, and recent studies that point to prescribing errors as the most frequent type of medication error in children's inpatient settings.

Drug errors can lead to child deaths or serious injury. The statistics show at least 200 children a year go home from hospital with life-changing injuries that could have been avoided had they been given the correct medication dosage. Statistics also show that 13 per cent of prescriptions given to children contain errors.

I currently have a case involving a child who contracted meningitis and, due to errors in prescribing, did not receive the correct dose to treat the condition. The child now has lifelong, hugely debilitating injuries that would have been avoided had they been given the correct dose. In another case, failure to correctly dose a neonate with low calcium levels on ITU contributed to permanent organ damage. We often see cases of children injured or killed by receiving incorrect doses of medication. 

There are higher risks of medication errors when treating children because, unlike for adults, prescriptions for children are usually personalised to each child. There is rarely a 'one pill fits all' solution. A drug that you would give an adult in a fixed dose whatever their age or weight has to be altered in every child's case to reflect their weight, age, gestation at birth and the format of the drug. Also babies and young children struggle with swallowing tablets and so tend to be offered the drug in liquid form if taking it orally, which increases the risk of overdosing.

For example, a six-day-old baby weighing 6.5lbs needing an antibiotic for suspected sepsis usually needs 130mg per kilo of the drug and you need to know the baby's weight to give the correct dose. If the medication is being given orally, rather than intravenously, the doctor also needs to covert the dose from a mg unit of measurement to a liquid measure, usually millilitres. Studies indicate that most errors are made by the nurse, paramedic or doctor responsible for writing up the prescription mistakenly calculating the dose.

HSIB released an interim report in March which identifies that increased reliance by the NHS on electronic prescribing systems could be contributing to errors. For instance, different systems are used within the same Trust and many prescribing systems are set to apply to adult dosing, and have to be manipulated to apply to children, which increases the risk of making an error.

Other sources of errors are, unsurprisingly, lack of experience of working with children, failures to follow medication guidance, and medication formulations as well as errors in calculating dosage. In our experience these errors are also due to a failure to follow established treatment and dosage guidelines. They also happen because of the most unforgiveable of errors – writing up a dose incorrectly or unclearly on the drug chart, a dose of, say, 50.00mg is written as 5000mg.

The Royal College of Paediatrics and Child Health is also conducting a two-year population study in paediatric tenfold medication errors. It too is finding that mistakes when calculating dose are a major source of the errors – mixing up measurement units, getting weight dose adjustments wrong, putting the decimal point in the wrong place or using the wrong conversion methods to convert an adult dose.

Solutions being considered are changes to the electronic prescribing systems, using mini pills with fixed dosages for children that can be given with water in a spoon because they melt into the water, and not assuming that older children cannot swallow tablet.

Pursuing a case on behalf of children who have been catastrophically injured following medication errors can obtain damages to help make day to day living easier and provide the help and support they need. But a child permanently scathed by medical error will always be unable to fulfil their full unimpaired potential.

The outcome of the research and the national investigate are awaited, and it is the hope and intention that it will lead to safer use of medicines in children, so reducing injury and deaths.

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Paediatrics Negligence