Medication errors involving intravenous paracetamol in children: experience from enquiries to the National Poisons Information Service (8 April 2024)

Summary

Children are at higher risk of medication errors due to the complexity of drug prescribing and administration. Intravenous (IV) paracetamol overdose differs from overdose by ingestion as there is no enteral absorptive buffering. This study outlines the first national UK data focusing on paediatric IV paracetamol poisoning.

The data show that unintentional IV paracetamol overdose appears to occur more frequently in young children. A significant proportion of errors were calculation errors, which were often 10-fold errors. While these errors have the potential to cause serious harm, thankfully most cases were asymptomatic. Errors with IV paracetamol might be reduced by electronic prescribing support systems, better communication regarding administration and consideration of whether other routes are more appropriate.