P5 Tenfold medication errors in children: welsh paediatric surveillance unit study 2017–8 – interim one year results

Abstract

Aim To establish the incidence and characteristics of tenfold or greater and a tenth or less medication errors in children Method Population-based incidence study in Wales, UK, from July 2017 – June 2018 (12 months). Cases were reported from paediatricians and hospital pharmacists using the monthly Welsh Paediatric Surveillance Unit (WPSU). Results 25 confirmed incidents in 23 children from 36 notifications were identified. Cases came from 5 hospitals in Wales with 12 (48%) from the sole tertiary hospital. Median age was 1.7 years and weight 10.7 kg (0.6 to 59). 22 were overdosing (up to 1000x fold error) and 3 underdosing. 22 different medications were involved, 10 (40%) intravenous. Of 15 cases involving enteral medication, 12 were liquid formulations. Two cases were discharge medication administrated at home by parents. Stage of errors were primarily in prescribing 20 (80%), administration 4 and dispensing 1. Ten (40%) cases reached the patient, six from prescribing. Two resulted in significant temporary harm requiring ICU admissions and the remainder received additional monitoring only without harm identified. Several human factor themes were identified: Prescribing confusion between gram milligram and microgram (none reached patient, n=4), confusing between mg and mg/kg (n=5 including all 3 underdosing errors), leading zero errors (e.g. 0.1 vs 0.001 mg, n=3) and prescribing reconciliation errors where admitting doctor attempted to prescribe chronic medication in mg by reversing calculating liquid dosage expressed in mls (n=4). Conclusion In this first ever population surveillance study, tenfold errors in children occurred at every stage of medication process and in the full range of care settings. Errors found were very different from those obtained from tertiary hospital single centre study and UK National Reporting and Learning System (NRLS). Strategies for error reduction will be more productive if designed across a whole national healthcare system.