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Written on 19th March 2021 by Susan Brown

The healthcare safety watchdog, HSIB, has raised concerns about the safety risk to children from prescription and medication errors. Their national investigation was prompted by an incident in which a four-year-old girl suffered a brain bleed in hospital after repeatedly being prescribed ten times the intended dose of a clot-busting drug for a DVT (blood clot) in her leg.

HSIB notes that 237 million medication mistakes (amongst adults and children) occur in England every year, during prescribing, dispensing, administration and monitoring. 66 million of these are potentially medically significant. Avoidable adverse drug events are estimated to cost the NHS nearly £98.5 million per year.

However, prescribing for children carries additional complications, leaving children at increased risk of injury from negligent prescription and medication. HSIB quotes research which has found that 13% of prescriptions for children contain errors.

Why are children at higher risk of injury from prescription and medication errors?

HSIB’s interim bulletin, Weight-based medication errors in children, raises safety concerns arising from doctors’ mistakes in calculating the correct dose of medicines, when the amount to be given depends on the child’s weight.

The additional risks to children in weight-based medication errors are illustrated by the example case that prompted HSIB’s national investigation and is used in the interim report. In that case, the child was in hospital with a complication from a heart procedure she had undergone some months earlier. When she developed a DVT (blood clot) in her leg, a multidisciplinary team recommended a prescription of a blood-thinning (anti-coagulant) drug, set at a dose which would balance her need to dissolve the clot with the risk of causing bleeding on the brain. They set the dose at 100units per kg twice a day. The child weighed 15.2kg, so her dose should have been 15.2 x 100units, rounded down to 1500units, but a junior doctor using the hospital’s electronic prescribing and medicines administration system (ePMA) inadvertently prescribed 15,000units of the blood-thinning drug twice daily.

This (apparently basic mathematical) error resulted in the child suffering a brain haemorrhage (bleed) after receiving ten times the safe dose for her weight on five occasions over three days. HSIB noted that the prescription error was not identified at any of the later steps in the process leading up to her receiving the medication, including the approval, dispensing, checking or administration stage.

HSIB point out that weight-based prescribing of medicines for children needs extra careful attention because each calculation and each dose is unique to the individual child. In this case, other contributing factors included the failure of double-checking procedures to prevent the incorrect dosage being administered, and the fact that the default calculation on the hospital’s ePMA system used for paediatric prescriptions auto-filled the adult dose and then needed the quantity to be adjusted by manual intervention.  HSIB noted, however, that similar prescription errors had been reported at the same hospital, both before and after the trust started using the ePMA system.

HSIB notes that the risk of injury to children from prescription errors is increased by a number of factors, including:

  • individualised dosing and calculations (which depend on the child’s unique growth, development and weight);
  • medication formulations;
  • communication with children;
  • experience working with children;
  • licensing issues.

Previous reviews have identified the need for further research to help understand the causes of medication errors in children.

HSIB has launched an investigation to improve safety by reducing the number of weight-based medication errors in children. The aim is to explore whether the healthcare system supports healthcare providers to prescribe, dispense and administer medicines safely. The investigation will primarily be focussed on prescribing for children but may also be relevant to other situations where dosage calculations are needed.

Medication, prescription and dosage errors should be avoidable with correct checking procedures and medical care but when they occur mistakes can lead to life-threatening and severe, permanent injury. If a patient suffers serious injury or permanent disability as a result of negligently prescribed medication, they may be entitled to substantial compensation.

If you have suffered severe injury as a result of medical negligence, and would like to find out more about making a claim,  contact us by email at