G107(P) Reducing paracetamol medication errors in children

Abstract

Introduction Paracetamol is one of the most common medicines administered to children nationally. Accidental overdoses with intravenous (IV) paracetamol in children Method MI were recorded and reviewed retrospectively every quarter (Q) from Q1 March-May 2018 to Q2 July-Sept 2019. Ethics approval was not required for this study. Selected measures were then used to track changes in incident numbers and trends on implementation of intervention. Measures Number of paracetamol incidents Level of harm Incident type – categorised into trends. Intervention 1 (Q3 October-December 2018) Paracetamol medication safety bulletin, highlighting risks associated prescribing paracetamol in children was circulated to staff. Standardised dosing approved in cross-site guideline. Targeted staff education around incident data, trends and top tips. Removal of multi-route screens on the electronic prescribing system to reduce number of IV paracetamol prescriptions. Intervention 2 (Q1 March-May 2019) Introduction of dose/volume checks for intravenous paracetamol included in the paediatric IV guide. Results Intervention 1 75% reduction in number of paracetamol errors. A 65% reduction in the total percentage MI involving paracetamol. 50% reduction in number of MI with a reported level of harm, the level of harm remained the same 100% reduction of oral dosing errors. 50% reduction in number of IV dosing errors for babies Intervention 2 No reported IV paracetamol dosing errors for babies Conclusion A significant level of harm has been reported with paracetamol MI in children. Regular review of MI numbers and trends, with targeted education and standardisation of practice can reduce number of MI, including those causing harm. Increased risk of adverse effects of paracetamol overdose in children means the level of harm was not reduced. Future work is needed to reduce incident numbers involving dose duplication.