NHS investigation body launches inquiry into medication errors in children

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 HSIB 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, 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.

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.

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Source: The Pharmaceutical Journal, 26 January 2021