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Reducing paediatric medication error through quality improvement networks; where evidence meets pragmatism
  1. Hilary Cass
  1. Correspondence to Dr Hilary Cass, Evelina London Children's Hospital, Westminster Bridge Road, London SE1 9RT, UK; Hilary.Cass{at}gstt.nhs.uk

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We cannot solve our problems with the same thinking we used when we created them.—Albert Einstein

Paediatric medication error (PME): the problem

Every day of our working lives we engage in healthcare encounters that have the potential to cause unintended harm to our patients. That harm can range from distress as a result of an insensitive remark, through misdiagnosis, to treatment errors involving procedures or medication. The National Patient Safety Agency,1 reporting on an international literature review, estimated an adverse event rate of between 2.1% and 10.8% of hospital admissions for patients aged 0–17. Fortunately, only a minority of these errors result in the most severe outcomes of death or permanent disability, but this is in large part because many common paediatric medications are tolerated well, and children are resilient in their response to therapeutic mishaps. The regular occurrence of errors points to serious vulnerabilities in the medication delivery process, and it is predictable that serious and fatal events will occur unless these processes are improved.

Drilling down on the causes of harm in healthcare settings, the most recently analysed data set from the National Reporting and Learning Service (NRLS),1 which receives incident reports for England and Wales, demonstrated that ‘medication errors’ were the most commonly reported incident type in the paediatric population (17% of incidents in children and 15% in neonates). The age group 0–4 years had the second highest percentage of medication incidents of all age groups, only exceeded by errors in those over age 75. Of course, despite being one of the world's most comprehensive databases of patient safety information, it is known that the lack of mandatory reporting makes NRLS information a gross underestimate of the true incidence of events, particularly in primary care. Moreover, within any one organisation a wide range of local and cultural issues influences both the …

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