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Perspectives: Helen Sammons and Sharon Conroy How do we ensure safe prescribing for children? Arch Dis Child 2008; 93: 98-99 [Full text] [PDF]

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letter in response to How do we ensure safe prescribing for children

SW Nicholls, Dr Urmilla Pillai¹Dr Anna Mathew¹Ms Saffron Mawby²   (12 June 2008)

letter in response to How do we ensure safe prescribing for children 12 June 2008
SW Nicholls, Paediatric Consultant Worthing General Hospital, Dr Urmilla Pillai¹Dr Anna Mathew¹Ms Saffron Mawby² Send letter to journal: Re: letter in response to How do we ensure safe prescribing for children stuart.nicholls{at}wash.nhs.uk SW Nicholls, et al.	Sir Your recent Perspective, ‘How do we ensure safe prescribing for children’ (1) highlighted an important and potentially avoidable cause of morbidity and mortality in childhood. We would like to add that significant errors in paediatric prescribing happen at the dispensing stage too, with between 2 and 58% of drug errors being related to dispensing errors (2). We briefly describe a case which highlights this problem and suggest ways to design out much of the error associated with the dispensing of paediatric prescriptions. A baby was assessed at 4 weeks of age to have cow’s milk protein intolerance and gastro-oesophageal reflux in out patients. At 16 weeks of age, he was prescribed an age and weight appropriate course of ranitidine together with a 3 ml syringe for the mother to give it. The drug was mistakenly dispensed as 3 mls of ranitidine rather than the 0.4 ml it should have been. Fortunately, the child had been prescribed ranitidine previously and the mother noticed quickly that she had been dispensed an incorrect amount. In our hospital, a typical British DGH, a single prescription form is available for use for prescriptions for all ages, in all departments. We suggest that the number of dispensing errors where children and young people are involved could be significantly reduced by incorporating some or all of the following suggestions to hospital prescription forms. All prescriptions should contain basic data including Title, Surname, Initials, Address, Date of Birth, Consultant, Unit Number, Date, prescribing doctor’s signature and contact details, and pharmacist dispensed by. Additionally, we suggest that prescriptions for children should – 1. Be manufactured in different coloured paper to adult prescriptions. 2. Be clearly stamped across the sheet ‘This is a paediatric prescription’ 3. Incorporate the child’s weight in a separate and clearly designated box 4. Specify dose per unit mass(e.g. mg /kg) 5. Supply should be specified by number of days in a separate column 6. Provide a separate section for prescribing non drug articles such as syringes, inhaler devices, dressing materials etc. These changes would serve to highlight to the pharmacy staff that the prescription was for a child and that appropriate attention was required to dispense the medication safely and correctly. We suggest that redesigning prescription forms for children in this way would be relatively simple and cheap to do, and have the potential to significantly reduce paediatric morbidity and mortality associated with paediatric dispensing errors. References 1) Sammons H, Conroy S. How do we ensure safe prescribing for children? Arch Dis Child 2008; Vol. 93, No2:98-99. 2) Miller M, Robinson, K, et al. Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations. Quality and Safety in Health Care 2007;16:116-126. Urmilla Pillai¹, Anna Mathew¹, Saffron Mawby², Stuart Nicholls¹ ¹Department of Paediatrics, Worthing Hospital, Worthing, UK. ²Pharmacy Department, Worthing Hospital, Worthing, UK