A systematic literature review was conducted to examine current knowledge regarding methadone toxicity in children. Methadone poisoning cases in the world were reviewed, as well as the number of methadone-related deaths. The databases searched were EMBASE, MEDLINE and PubMed. All relevant titles, abstracts and full articles were obtained and read.

38-eight studies were identified which included a total of 62 children (3 weeks–13 years; median=2 years). Of the 62 cases, 26 cases were reported in the USA, 12 cases in the UK, six in France, five in China, four in Canada, two in Germany, one in Switzerland, one in Italy, one in Austria, one in Portugal, one in Poland, one in Slovakia and one in Malaysia. Twenty-nine children died due to methadone toxicity. Methadone plasma/serum concentrations were measured in 27 cases (22 died and 5 survived). The methadone plasma/serum concentrations in the 22 children who died range from 60 to 1200 µg/l (median: 385 µg/l). The plasma/serum concentrations of methadone in the five children who survived ranged from 30 to 360 µg/l (median: 100 µg/l). The common signs and symptoms were central nervous system depression 92% (n=57), respiratory depression 58% (n=36) and miosis 50% (n=31). It is not possible to be certain as to how many children were deliberately poisoned and how many cases were accidental. It is likely that most of the 11 infants (<12 months old) were poisoned deliberately. In three cases, the methadone was a contaminant in an antibiotic suspension.

Methadone is a dangerous drug for children, because ingestion of tiny amounts can lead to death. A common cause of accidental poisoning of children is careless storage. Methadone toxicity is characterised by respiratory depression, central nervous system depression and miosis. There are overlaps between toxic and fatal concentrations. Accidental poisoning with methadone can be reduced by the education of patients, supervision of methadone consumption, dispensing of methadone doses in resistant bottles for children and storage of methadone in safe places.

To determine the existing evidence base for the effectiveness of double checking processes in reducing medication error rates in prescribing, dispensing and administration.

A systematic search of studies that assessed or evaluated double checking during the medication treatment process was conducted for adults and children using the following databases: Embase, Medline, British Nursing Index & Archive, Cumulative Index to Nursing & Allied Health Literature (CINAHL) and PsycINFO. The title, abstract and full article were reviewed for relevance. Studies not related to double checking medication were excluded.

Only 14 studies were identified as being relevant. Three studies were quantitative. Seven studies were qualitative (questionnaire and interviews). Two studies used mixed qualitative and quantitative methods. Two studies were systematic reviews. One of the three quantitative studies reported a statistically significant reduction in the error rate from 2.98 when using two nurses for drug administration to 2.21 when drug administration was performed by a single nurse but the clinical advantages of the double checking process were stated to be uncertain.1 Another quantitative study reported that a double checking policy introduced for all dispensed medicines by pharmacy staff led to a reduction in errors from 9.8 to 6 per year.2 The third study was a simulation study comparing two checklists (old checklist vs new checklist) for an ambulatory infusion pump used in a chemotherapy unit. It found that there was no significant difference in detection of pump programming errors, but detection of errors in patient identification with the new checklist (80%) was significantly higher than with the old checklist (15%).3

There is insufficient evidence to confirm that double checking of medication reduces the risk of medication errors. This does not mean that double checking is ineffective but simply that its effectiveness has not yet been proven. More research is required to examine the effectiveness of the double checking process.

An evaluation of four point prevalence surveys (PPS) conducted on a single day in January 2009, January 2010, November 2010 and May 2011 and three snap-shot prescribing surveys (SSPS) conducted on a single day in November 2009, February 2010 and May 2010. All inpatients on the days of the surveys were included. Patients' medical notes, medication charts and laboratory data were reviewed and data was collected on diagnosis, antibiotic(s) prescribed, route of administration, duration of treatment, documentation of an indication and duration/review date and compliance with local prescribing guidelines. The data were analysed using Excel.

The total number of patients included across all surveys was 1410. 503patients (35.7%) were prescribed treatment courses of antibacterials.

Over the course of four PPS a sustained reduction in cephalosporin use was observed from 26/61 (42.6%) patients prescribed antibacterials in January 2009 to 5/61 (8.2%), 6/77 (7.8%) and 5/60 (8.3%) in the subsequent three PPS. Meropenem use decreased from 9/61 (14.8%) in January 2009 and 15/61 (17.2%) in January 2010 to 9/77 (12%) in November 2010 and 6/60 (10%) in May 2011. The proportion of patients on intravenous antibiotics remained high at 49/61 (82%), 45/61 (74%), 64/77 (83%) and 38/60 (63.3%). However, the number of patients receiving intravenous antibiotics for >48 h decreased from 40/49 (82%) to 33/45 (73%), 37/64 (58%) and 18/60 (30%).

Over the course of the three SSPS, the documentation of an indication on patients' medication charts has increased from 5/53 (9%) patients prescribed antibacterials in November 2009 to 30/60 (50%) in May 2011. The documentation of a duration/review date on patients' medication charts has increased from 7/53 (13%) in November 2009 to 27/60 (45%) in May 2011.

A programme of antimicrobial stewardship has been successfully introduced in accordance with national requirements.1 A sustained reduction in agents at high risk of causing Clostridium difficile associated disease, agents with a broad spectrum of activity and the duration of intravenous therapy has been achieved in line with national recommendations.2 3 The quality of antibacterial prescribing has also improved in line with national guidance.2 3 There has been little impact on the proportion of patients treated with intravenous agents although this may be expected in paediatrics.

Medicines administered to children and neonates were reviewed over 4 weeks in January to February 2010. Every time a medicine was administered the drug name, brand or manufacturer and dose prescribed were recorded. Data were collected within general paediatric and emergency care assessment wards and within a level three neonatal unit (NNU). The excipients within each medicinal product administered were found using the SPC, or by contacting the manufacturer directly. The suitability of each individual excipient was assessed following literature review.

759 doses of medicine were logged. 80 different medicines were administered. 44 excipients were identified that were potentially unsuitable for use in children and neonates. From a literature review of the relative safety of each excipient they were grouped into four classes. Excipients that have potential harmful effect, which should be considered when prescribing. These included: acetone, aspartame, benzoic acid, benzyl alcohol, chloroform, citric acid, ethanol, galactose, methylhydroxybenzoate, phenol, polysorbate 20 and 80, propylene glycol, sodium benzoate, sodium bicarbonate, sodium chloride and sodium dihydrogen phosphate. Excipients with potential harmful effects only in extremely high concentrations. These included: diethanolamine, disodium edetate, hydrochloric acid, sodium carbonate anhydrous, sodium hydroxide, sucrose, sulphuric acid and triethyl citrate.

Excipients with potential to affect the gastrointestinal tract in excess and cause flatulence or act as a laxative. These included: carboxymethylcellulose sodium, croscarmellose sodium, hypromellose, magnesium stearate, maltitol liquid and mannitol. Excipients with potential to cause an adverse drug reaction, such as hypersensitivity and anaphylaxis. These included: cetyl alcohol, lactose, polyoxyethylene hydrogenated castor oil, potassium sorbate, propylhydroxybenzoate and butylhydroxybenzoate, protamine sulphate, saccharin sodium, sodium lauryl sulphate, sodium metabisulphate, sorbitol and tragacanth. On paediatric wards some products contained up to five potentially harmful excipients. On NNU most products used contained only one potentially harmful excipient.

Excipients used within medicinal products that are given to children and neonates, often from adult formulations, may not be safe. The quantity of each excipient should be advertised on each medicinal product to enable an informed choice to be made on its relative safety in the neonatal and paediatric setting.

No clinical standards or guidelines currently exist relating specifically to paediatric outpatient prescription requirements, however the Trust's policy for prescribing medicines should be adhered to where relevant. Data were prospectively collected using a piloted form, by the screening pharmacist, for all paediatric and A and E outpatient prescriptions during a 1-week period. The data were then broken down into the five main clinic groups and each standard looked at individually to identify areas for improvement.

158 outpatient prescriptions were dispensed during the study period, with a total of 314 items. 53% (166/314) of items prescribed required a pharmacist intervention, however only 7% (23/314) required the prescriber to be contacted. The majority of the queries were resolved by communicating with the patient or carer. 40% (63/158) of prescriptions did not have a documented allergy status, 30% (15/50) no patient weight where appropriate and 5% (8/158) no date of birth.

Prescriptions from A and E were most likely to require pharmacy interventions; 82% (38/48) required a pharmacist intervention, 77% (27/35) had no allergy documented and 64% (7/11) had no weight documented when this was necessary for dosing.

There were a number of limitations to this audit. Limitations include data collection over a restricted time period, and potential bias from different pharmacists carrying out the data collection.

Paediatric outpatient and A and E prescriptions at St Mary's Hospital are not meeting the set standards. The focus for improvement needs to be in paediatric A and E, where prescriptions are often lacking in patient information and pharmacists most frequently have to make interventions. This is probably because that the paediatric A and E prescription is different from the other outpatient prescriptions and does not have an allocated space for the prescriber to document the weight and allergy status. As a result of this audit, the A and E outpatient prescriptions will be amended; results of the study will also be fed back to the paediatric doctors.

Prescription and laboratory data for patients receiving vancomycin was collected and analysed for a 6 month period following guideline introduction. This data was compared with results obtained from the previous audit.

Before guidelines were introduced the 2008/2009 audit showed target trough levels of 10–15 mg/l were achieved in 7% of initial levels taken, 23% of levels overall and 28% of levels following final dose adjustment. 49% of final levels were between 8–18 mg/l. 15 mg/kg three time a day was prescribed for most patients with normal renal function. Prolonged periods of subtherapeutic levels were common. Inadequate dose adjustment and delays for levels to be processed contributed to the problem. Insufficient attention was given to adjusting doses in patients with renal impairment and monitoring was variable.

Following guideline introduction the 2009/2010 audit showed target trough levels of 10–15 mg/l were achieved in 17% of initial levels taken, 34% of levels overall and 56% of levels following final dose adjustment. 82% of final levels were between 8–18 mg/l.

The guidelines split initial dosing recommendations into four categories according to known or anticipated renal function and introduced a higher initial dose of 20 mg/kg three time a day for children with normal renal function. 69% of patients were initially dosed according to the guidelines.

Guidelines have improved the quality of vancomycin prescribing on the Unit and the percentage of target levels achieved has significantly increased.

The increased initial starting dose of 20 mg/kg three time a day for children with normal renal function has been extended to all children in the Trust.4 Minor amendments have been made to the guidelines. It is recommended that the guidelines are adopted by all Child Health wards to provide the same guidance on prescribing, monitoring and dose adjustment.

Design a safe and effective method of prescribing medications via continuous variable rate infusions on PHDU. Ensure prescribing is compliant with current EPR application (Lastword).

Electronic screens were designed using the PHDU variable rate infusion prescribing guide, which was adopted from the Children's Acute Transport Service protocols.2 Screens were placed within a PHDU index in the paediatric formulary on Lastword to centralise the location of the screens and reduce the risk of incorrect drug selection. Screens display all relevant prescription information: patient demographics (including weight) amount of medication in syringe, diluent, total volume of syringe, infusion rate and dose range. To reduce prescribing errors the recommended dose ranges were defaulted into those medication screens deemed the highest risk. The frequency for all infusions was defaulted to ‘every 24 h’, ensuring that new prescriptions were automatically scheduled each day, and that they could be reviewed regularly. Training was provided to all the pharmacy and PHDU staff.

EPR screens were designed on Lastword in order to hold key prescribing information. Use of default doses prompted doctors of the recommended doses of each infusion, which were used in conjunction with PHDU prescribing guide. Use of a specialty index allows segregation of the screens, reducing the risk of mis-selection of drug by prescribers. Hourly recording of infusion rates could not be completed electronically. This information was recorded on the patient's paper continuous monitoring sheet.

To date, the electronic screens have been used successfully for a small number of test patients, the full impact on patient care and prescribing errors will be evaluated next year. The design of the screens allows for all prescription details to be shown electronically, with the advantage of reducing the risk of having two systems in place (eg, Carevue or paper) and allowing for recommended dose ranges to be defaulted. The main disadvantage of EPR was that hourly rates of infusion could not be recorded electronically and infusion rates had to be calculated manually. EPR is used on many paediatric wards across the UK however there is currently only one PICU using it. The authors hope to have designed a safe and practical way to prescribe variable rate infusions electronically, the concept of which can be shared with other units.

A data collection sheet was designed and reviewed by the paediatric cardiac pharmacist, a cardiac nurse specialist and a paediatric cardiology registrar. The data collection was conducted by a medical student during the period of 28th June 2010 and 7th July 2010. All paediatric congenital heart disease inpatients during the study period were included in this preaudit data collection exercise. A retrospective study of patient medical notes and the paediatric congenital heart database (Heartsuite) was conducted between 1st July 2009 and 31st May 2010. The data collection reviewed; documentation in the patient's medical notes regarding commencement of warfarin, the loading dose given, the loading regimen over days 2–7 and the international normalised ratio (INR) target at discharge.

There were eight new patients commenced on warfarin during the study period; seven postsurgery and one post pulmonary embolism. Documentation in the medical notes was variable; no documented reason why warfarin started or that verbal or written information given to patient/parents, the majority of loading doses used were documented and all of the INR results post surgery was detailed.

As regards loading and target ranges; less than half of patients complied with the day 2–7 loading regimen protocol during the study period but at discharge seven out of the eight patients were in target range. The post discharge INR results were 46% within range, only one patient had an INR of greater than five and none had an INR greater than 8.

This data collection has highlighted that documentation and prescribing could be improved by the production of a comprehensive guideline that highlights the NPSA recommendations in Alert 18 that can be used within our department and regionally. This data collection has also shown that less than half of patients adhered to the current loading regimen that was used during the collection period, so our loading regimen used will need to be reviewed. Despite this there were no reports of adverse events such as major bleeding and only one patient had an INR greater than 5. Once a guideline has been written and approved, all of the standards outlined in this data collection will need to be re-audited.

Data collection was completed by two pharmacists, one at St Mary's Hospital (SMH) and one at Queen Charlotte's and Chelsea Hospital (QCCH), over 4 weeks during December 2010 and January 2011. A piloted data collection form recording compliant, non-compliant or not applicable was used. Up to 10 charts that were previously unseen by a pharmacist were audited each week. If 10 charts were not eligible then unscreened newly prescribed items were audited against standards 3–5. Patients could be audited more than once.

75 charts were audited (SMH n=35, QCCH n=40), 47 were for new patients, 11 were rewritten charts and 17 were just for new items. 58 charts were used to assess standards 1 and 2. On average, each patient was prescribed between two and three medications. SMH had lower adherence to standards 1 and 2 compared with QCCH but standards 3–5 scored comparably. No standard received 100% compliance across both sites, and only one component, whether the correct patient surname was recorded on the drug chart, fully complied.

There are failings on both sites with adherence to prescribing standards. Particularly low compliance was recorded for the cancellation of discontinued medicines at QCCH and recording of hospital numbers at SMH. The limitations of this audit include the use of two data collectors, whose perceptions may differ for standards 3–5, different sample sizes between the two sites and the number of newly prescribed items assessed. Extra pharmacy training is recommended to provide more support for prescribers followed by regular audits with timely feedback.

A comprehensive systematic literature search was performed searching for the use(s) of warfarin. Once a good background into the clinical uses of warfarin was obtained; patient notes and documentation were looked through for adherence to the warfarin NPSA alert. Adherence was based on specific audit standards derived from the NPSA such as international normalised ratio (INR) levels being documented on drug charts and an indication for warfarin being stated in the notes. Warfarin clinics were visited in which the anticoagulation team provided a good background into the overall prescribing processes of warfarin within BCH.

With top line evaluation results identifying two patients to be on concurrent interacting medicines with warfarin (which were not acknowledged), and two patients who had lost drug charts; it remains evident that factors previously identified as leading to warfarin incidents, have continued to happen whilst not precluding its clinical use. Almost 62% of patients had warfarin appropriately prescribed (with regards to stating the drug name, form, route of administration, dose given and monitoring of INR) with 30.7% of patients having corresponding INR monitoring sheets with their drug charts. There was a 28.6% adherence to the expected audit standards, mainly due to missing INR levels being recorded on drug charts. The most profound reason for this was due to the issue of lack of communication between healthcare professionals and a breakdown in processes regarding safe warfarin prescribing, which could be improved by more education and training for all staff.

As The authors emerge into an era of increased polypharmacy, the importance for pharmacovigilance has never been more important. More needs to be done in order to increase adherence to local and national guidelines to encourage safe prescribing and more paediatric warfarin patients need to be audited for further conclusive evidence. Areas for improvement that were suggested included proposing a universally accepted protocol for the safer use of warfarin for all clinicians within BCH to implement; and implementing a cautionary warning on the Lorenzo system (electronic software in BCH that records all patient details upon admission) prompting the transfer of warfarin documentation onto current patient files to be used on the ward, so that the most up to date information can be viewed by the multidisciplinary team upon admission. Only then can The authors aim to halt the national instances of warfarin induced fatalities and toxicities.

Patients admitted to NUH with febrile neutropaenia between August and November 2010 were identified from clinical notes. PEWS data and CRP values were collected at admission, 24 and 48 h from nursing observation charts and the NUH results system (NotIS) respectively. Antibiotic levels were retrieved from NotIS. The door to antibiotic time was calculated from the admission time recorded on nursing admission notes and the time at which the first dose of antibiotic was documented on the drug chart.

Data were collected from 20 patients aged 1.3–16.6 years (median 9.4 years). 13 patients (65%) were started on first line antibiotics in line with the NUH febrile neutropaenia guideline. Two patients were incorrectly given gentamicin as they were receiving nephrotoxic chemotherapy regimens. Gentamicin levels were available for 17 patients. 14 patients (82%) had levels taken correctly of which eight patients (57%) were within the specified range and 5 (36%) had low post dose levels. Median PEWS scores was 4 (20 patients) and CRP was reported on admission for eight patients (mean 10). Five patients had positive blood cultures but none were admitted to intensive care or died. The door to antibiotic time was determined in 11 patients and was less than 1 h in five patients (45%, mean 94 min).

The majority of patients received first line antibiotics in accordance with the NUH febrile neutropaenia guideline. Since this review was completed the Trust has switched to once daily dosing of gentamicin and there has been a new guideline publicised. As a consequence of this change it is imperative that pre dose levels are measured correctly but post dose levels are no longer required. This review did not demonstrate any correlation between CRP or PEWS score and positive blood cultures or length of stay however larger studies are needed to investigate this further. In nearly half of patients the door to antibiotic time could not be determined from the medical or nursing notes. This highlights the need for a more robust system to be in place to record the time that patients present to hospital.

Six bibliographical databases (Medline, Embase, CINAHL, International Pharmaceutical Abstracts, Web of Science and Biosis Previews) and selected key words were used to find epidemiological studies on medication discrepancies in children upon hospital admission, transfer and discharge (key words included ‘medication discrepancy’; ‘medication reconciliation’; ‘hospital admission’; ‘hospital discharge’; ‘hospital transfer’); studies where the data for children could be extracted were included.

From the 1239 articles found (in May 2011), eight of the articles had extractable paediatric information, (five from Canada, two from USA, one from UK). Five of the studies involved discrepancies on admission, one involved discrepancies on admission and transfer, one involved discrepancies at transfer and one considered discharge. The reference point used to compare against the admission, transfer and the discharge order differed in each of the studies. Four studies used a rating scale to assess the clinical significance of the discrepancies to demonstrate the potential adverse clinical outcome of patients in the absence of clinical intervention. Two studies2 3 used a rating scale that was used in adults.4 A study of paediatric neurosurgical patients found that initial hospital prescriptions for children differed from the preadmission prescriptions in 39% of occasions and 50% of all prescribing variations had the potential to cause moderate or severe discomfort or clinical deterioration.2 A study by Coffey et al in general paediatric admissions in Canada showed 22% of patients experienced at least one discrepancy and 29% of the discrepancies had the potential to cause moderate or severe discomfort or clinical deterioration.3 By comparison an epidemiological study in discrepancies in adults on admission had 38.6% of the discrepancies identified with a potential to cause moderate or severe discomfort or clinical deterioration.4 All the studies involved small samples or specific patient groups such as medically complex patients. However all of the studies demonstrated that discrepancies occurred among paediatric populations during transitions in care settings and mentioned MR as an intervention.

The results have shown that discrepancies of medication upon hospital admission, transfer and discharge occur regularly in children. With only one published study in the UK looking at hospital admission in children, and no published articles on the incidence and epidemiology of medication discrepancies upon hospital transfer or discharge further research is required in a wider paediatric population. Further work is also required to define the required interventions to improve practice.

501 consecutive discharge medication orders from 142 patients were examined and the following records were compared (1) the final inpatient drug chart at the point of discharge, (2) printed signed copy of the initial to take away (TTA) discharge summary produced electronically by the physician, (3) the pharmacist's amendments on the initial TTA that were hand written, (4) the final electronic patient discharge summary record, (5) the patients final take home medication from the hospital. Discrepancies between the physician's order (6) and pharmacist's change(s) (7) were compared with two types of failures – ‘failure to make a required change’ and ‘change where none was required’. Once the patient was discharged, the patient's GP, was contacted 72 h after discharge to see if the patient discharge summary, sent by post or via email, was received.

Over half the patients seen (73 out of 142) patients had at least one discrepancy that was made on the initial TTA by the doctor and amended by the pharmacist. Out of the 501 drugs, there were 140 discrepancies, 108 were ‘failures to make a required change’ (77%) and 32 were ‘changes where none were required’ (23%). The types of ‘failures to make required changes’ discrepancies that were found between the initial TTA and pharmacist's amendments were paracetamol and ibuprofen changes (dose banding) 38 (27%), directions of use 34 (24%), incorrect formulation of medication 28 (20%) and incorrect strength 8 (6%). The types of ‘changes where none were required discrepancies’ were omitted medication 15 (11%), unnecessary drug 14 (10%) and incorrect medicine including spelling mistakes 3 (2%). After contacting the GPs of the discharged patients 72 h postdischarge; 49% had received the discharge summary and 45% had not, the remaining 6% were patients who were discharged without a GP.

This study shows that doctor prescribing at discharge is often not accurate, and interventions made by pharmacist to reconcile are important at this point of care. It was also found that half the discharge summaries had not reached the patient's family physician (according to the GP) within 72 h.

The age, weight and medicines prescribed for patients on PICU were collected for a 6 week period. The doses were converted to the volume that would be required for administration. Volumes of less than 0.2 ml were labelled as a small dose volume for the purpose of this study. Medical staff were asked whether they were aware of potential inaccuracies of small dose volumes and if this would change their clinical management of the most commonly prescribed medicines on the unit.

There were 269 (10.8%) prescriptions for small dose volumes (<0.2 ml), involving 44 different drugs and 1552 (7%) administered doses during the data collection period. Mean weight of the patients was 14.2 kg (±17.6) and average weight of patients receiving small dose volumes 5.04 kg (±4.08). 25% of the patients were prescribed at least one drug requiring small dose volume. Infants under 6 months received on average three small dose volume prescriptions but one in four patients were prescribed a drug which would require a small dose volume. Captopril, morphine, furosemide and ranitidine were the most common drugs administered in volumes less than 0.2 ml. Small dose volumes were more often administered via the intravenous route. One in 10 medicines stocked on the PICU require small dose volumes for patients less than 5 kg, and 1 in 30 for patient 5–20 kg. The intravenous route was involved in 8 out of 10 small dose volume medicines prescribed. Medical staff expressed concerned of potential over or under dosing occurring without awareness and would adopt changes in frequency of clinical observations for certain but not all medications.

This small study shows that small dose volumes are used in all ages and weights of patients on the PICU but more commonly in the under 6 month patient. More data is required to identify medicines of higher risk that may require alterations in observations in the smaller patient. As a large number of medicines are involved in small dose volume measurements a medicine delivery system is required to decrease the risk of inconsistent and inaccurate doses to the paediatric patient.

A retrospective review of the medication administration records (MAR) on PICU and a literature review of missed doses was undertaken. Doses omitted from regularly prescribed medicines; continuous infusions and stat doses were included in the study. Reasons for omissions were recorded from the MAR by noting the number assigned by staff or from written documentation in patients' medical notes. A multidisciplinary panel was asked to give their opinion of the clinical significance of omission using the National Reporting and Learning Scheme scoring system. The severity classification assigned by the panel was compared with the UK MI tool to support the NPSA Rapid Response Report Reducing Harm from omitted medicines in hospital and the Trust local implementation list published postanalysis.

There were 1995 prescribed doses for 18 patients, of which 129 (6.5%) doses were omitted. Authorised that is doctors request, awaiting levels or no access to give medicine accounted for 34 (26%) omissions. Of the 95 unauthorised omissions, 87 (67% total omitted doses) were not assigned justification for withholding the dose on the MAR or in the medical notes. There was no documentation in the administration box or in the medical notes on five occasions and it could not be confirmed if dose given or not. On four occasions the drug was not available in the clinical area. Anti-infective drugs were the highest group of drugs omitted followed by electrolytes. Lack of access was a common indication for electrolyte omission. Oral and naso-gastric routes were omitted on 81 occasions, and 48 (37%) intravenous doses were omitted. None of the omissions were reported via the Trust medication incident system. The panel assigned severe potential harm to 26 (20%) of the omissions, and moderate potential harm to 40 (31%). All the potential severe harm group were drugs to be administered via the intravenous route. Anti-infective, diuretic and corticosteroid omissions were considered as the most serious unauthorised medication exclusions. The panel expressed difficultly in deciding if a withheld dose was appropriate. The ‘no patient risk impact’ is quoted in the UKMI tool for anti-infective or intravenous diuretics whereas the panel considered the highest patient risk impact. Corticosteroid omission in the UKMI tool is only considered significant when indication is post-transplant, whereas the panel considered omission in a premature infant for lung disease to be of concern. Diuretics are not included on the local Trust list of drug that requires timely administration in relation to prescribed time.

This small study shows medicines omission rates on PICU are slightly lower than quoted in the literature. However, improvement in the documentation for withholding doses is required on PICU to ensure appropriateness and to assign potential significance to patient harm.

Patients with central venous access requiring TPN on PICU were included in the data collection; patients receiving any enteral intake were excluded. Weight, fluid allowed, TPN prescription, TPN intake, volume of continuous infusions and reasons for withholding TPN were recorded. The desired calorific intake was calculated using values from the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) TPN guidelines. A proposed standard PICU TPN bag formulated was compared with actual intake of the patients included the study.

16 patients with a mean of 4.24 kg (range 0.88–18 kg) received 159 days of parenteral nutrition during the data collection period. Over two thirds of TPN days allowed 100% maintenance fluid or above to be given, however on 42 (26.4%) days the patients were restricted to less than 80% of normal daily fluid allowance. On 62 TPN days the patients were receiving over 10% of their allowed fluid intake as drug infusions. The mean daily fluid allowance given as TPN was 74% of the prescribed fluid allowance. On 62 (38.9%) TPN days over 95% of the prescribed TPN was delivered to the patient, however on 41 (25.7%) days less than 80% of the prescribed TPN reached the patient. Only 66 (41.5%) TPN days provided the desired nutritional intake, 42 days provided between 80 and 95% of the patients required intake and on 51 TPN days the patient received less than 80% of their desired nutritional intake. In 43 of the 51 TPN days where less than 80% of the desired intake was achieved, the proposed PICU standard bag could have been fully administered. More calories would have been delivered on each of the 51 days.

Table 1

Showing constraints associated in patients achieving less than 80% of desired nutritional intake in comparison to the total data collection

The calories a PICU patient prescribed TPN frequently does not provide the desired nutritional intake due to a number of factors. This study shows that a fluid restricted PICU patient will receive more calories from a standard TPN bag than a bespoke formulation; and this may provide financial and productivity savings for PICU.

A retrospective analysis of patient drug charts and medical records (including electronic biochemical records) on two general surgical wards during a 5 day working week. The following details were recorded: consultant team, procedure undertaken, type of intravenous fluid prescribed, the rate prescribed, does it contain potassium and if so the concentration prescribed, weight of the patient and number of times patient was re-weighed, duration of intravenous fluid prescribed, frequency of monitoring for sodium and potassium levels while on intravenous fluids. The data was analysed using Microsoft Excel 2007.

25-patients were reviewed from 17 consultant teams from different specialities. More than half of the intravenous fluids prescribed were by a surgical team (56%). The average age of patients was 4 years and 4 months (range: 3 weeks to 16 years) and 60% of the patients were female. The average weight was 16.25 kg (range: 3.56 kg–53 kg). In terms of monitoring for sodium and potassium levels, about 35% of patients were not monitored. In terms of the rate prescribed, 44% of patients were prescribed an incorrect rate with no reason why the rate was prescribed. All patients were initially weighed on admission but none of the patients were re-weighed daily while on intravenous fluids.

19 (75%) of patients assessed for appropriate intravenous fluid prescribing did not comply with local and national guidance and failed to meet the standards for this audit. 92% of patient were prescribed incorrect fluid type postoperatively in relation to local guidance,1 however 100% of patients complied to national standards2 for peri-operative fluid choice and 28% of patients with a low sodium episode had no changes to their intravenous fluid type prescribed.

Inconsistencies in prescribing were identified in all consultant teams. These mainly included the choice of fluid, the rate prescribed, lack of monitoring and lack of weight monitoring in all cases. This raises the risk of injury to the patient from hospital-acquired hyponatraemia. Training needs to be improved within all consultant teams prescribing intravenous fluids to improve current trends and to adhere to local and national guidance, in order to reduce this potential risk.2

Questionnaires, comprising of 10 questions, were distributed to approximately 25% of our child health nursing staff, across all shift patterns and nursing bands. Nurses were given 15 min during their shift to complete the questions individually and without conferring afterwards; they were returned anonymously via internal mail. All necessary information was included in the question. The questions were rated according to the number of manipulations required: 1, 2 or 5.

80% of the 55 questionnaires distributed were completed and returned, resulting in data from 22% of the total nursing staff. Overall, 87% of questions were answered correctly.

With the exception of question 5, the questions were answered correctly by 90% of band 5, 96% of band 6 and 100% of band seven nurses. This shows that questions with only one or two manipulations were answered well, but the percentage is considerably lower for question 5, which required five manipulations and was more complex. Question 5 was answered correctly by 47% of band 5, 10% of band 6 and 50% of band 7 nurses. Overall the questions, all of the paediatric wards scored 83% or above, except the outpatient department and the day ward.

Medication errors are one of the most common types of medical error, and include prescribing, dispensing and administration errors.1 Possible causes of error include individualised dosing, as doses are calculated according to the patient's age, degree of prematurity in neonates, weight, body surface area and clinical condition.2 The lack of appropriate paediatric formulations also results in the need for additional calculations to be completed to ensure that the desired dosage is administered. Simple calculations requiring one or two manipulations were answered well across all nursing bands and inpatient wards, but the percentage of correct answers with the more complex question, was considerably lower. Overall, basic calculation skills across child health appear to be at a high standard, but further work is needed for calculations requiring multiple steps. The majority of these questions related to oral medicines, therefore a follow-up audit focusing on intravenous medicines, either bolus or infusions, should be completed in the near future. Paediatric and neonatal intensive care will also be included.

The details of all patients receiving vancomycin on our neonatal unit between 1 April 2010 and 31 March 2011 were collected retrospectively from pharmacy Centralised Intravenous Additive Service orders. Data on vancomycin prescribing, therapeutic drug monitoring and dose adjustments were collated from the patients' medical records and biochemistry data, to capture usual practice on our unit.

39 patients were recruited into the audit, but data was only available for 37. The corrected gestational age of patients ranged from 25⁺⁵ to 60 weeks and the weight from 0.415 to 7 kg. 71 courses were given, ranging from 3 to 58 doses; a mean of 13.46 doses per patient. 96% were prescribed the correct dose, 85% were written clearly and correctly, 93% were given within 1 h of the prescribed time and 73% of first levels were taken pre third dose. 26% of initial trough levels were 10–15 mg/l; dose adjustments increased this to 60% by the last level taken. 54% of doses were administered when the serum vancomycin trough levels were not in range. The mean number of doses before a serum level was >10 mg/l was 4.96. Analysis of the data shows that patients up to 33 weeks needed 30 mg/kg/day and 33–44 weeks needed 45 mg/kg/day or more. There is not enough data to evaluate patients greater than 44 weeks gestation.

Vancomycin is an important glycopeptide antibiotic used to treat Gram positive bacterial infections.1 but it is essential to monitor serum trough levels to enhance efficacy.2 The primary aim was to establish whether our dosing regimen achieves therapeutic vancomycin serum levels. From this data, it can be concluded that a new dosing regimen is required. The proposed schedule is 15 mg/kg/dose 12 hourly if corrected gestation ≤32 weeks, increasing to 8 hourly for 33–44 weeks. Patients with a corrected gestation greater than 44 weeks should then follow the Trust's paediatric vancomycin dosing regimen, which starts at 20 mg/kg 8 hourly. Once an initial dose has been established, it can be seen that further guidance is needed for monitoring and dose alterations.

Data were collected over a two month period on 20 patients from paediatric wards at The Royal London Hospital during January and February 2011. Patients were identified by the paediatric pain clinical nurse specialists (CNS) from the following inclusion criteria:

Data collected included whether intravenous ondansetron was prescribed, whether the dose of 0.1 mg/kg was used, number of doses given, number of vomiting episodes, whether a nasogastric (NG) feeding tube was in situ and if it was regularly aspirated.

Nine patients (45%) had ondansetron prescribed, zero received any ondansetron, three (15%) had a recorded number of vomits, eight (40%) had a NG tube in place while on NCA, of which all eight were regularly aspirated. No patients required any ondansetron while on NCA. The three patients who vomited did so immediately after feeding and considered a fault of possetting rather than NCA or surgery related. Despite Trust guidelines only 45% of patients audited were prescribed ondansetron. All NG insertion and aspiration occurred on the high dependency neonatal surgical ward. Many of these patients return from theatre nil by mouth and the usual practice is to aspirate the NG tubes on an hourly basis until the doctor decides that the patient can slowly be re-introduced with feeds. The patients who vomited did so immediately after feeding and the size and severity was considered small and minor. Retrospective data collection for two patients who vomited showed they underwent gastroenterology surgery (closure of colostomy) and pyloplasty respectively.

With no doses given it is recommended that ondansetron no longer be prescribed routinely for this patient group. This allows doctors to review the severity of vomiting and prevents unnecessary administration. Further data collection (higher patient numbers and type of surgery) is needed to consolidate the findings.

Data were gathered retrospectively spanning a 2 week period. All patients receiving PN in this period were examined. An audit proforma was designed to record omitted components. If the prescriber's intention for the requirements were unclear this was also documented. Prescriptions were defined as ‘intention unclear’ if the prescriber had omitted components and not stated ‘no change from previous date’ on the prescription. A questionnaire was also sent to all PN prescribers to gain qualitative information about their PN training and confidence in prescribing.

86 prescriptions were received from four specialties. 78% of prescriptions were defined as unclear. A high proportion of prescriptions (84–92%) did not have the nutritional components (macronutrients, electrolytes, vitamins) fully prescribed. An equally high proportion (83%) did not specify the route of administration as central or peripheral. Over half of the prescriptions did not have the patient's weight recorded or the total fluid needed. 62% of the prescriptions did not state the duration of the PNA small proportion (7%) of the prescriptions were not signed resulting in further interventions from pharmacy. 12% of PN prescribers had received no training. Half of the prescribers had received training in the form of hospital induction training. Over a third of prescribers received training classed as ‘other’ training. This consisted of ‘on-the-job’ training and previous experience from other Trusts. 87% of prescribers felt that they would like further training in PN prescribing.

This audit has demonstrated poor adherence to the Trust Medicines Policy. A high proportion of prescriptions have omitted components and the prescriber's intention is therefore unclear. This audit highlights the need for increased training of PN prescribers and increased awareness of the Medicines Policy. There is a need for further work to evaluate whether PN prescribing should be limited to a nutritional team as recommended by other studies such as National Confidential Enquiry into Patient Outcome and Death.2

Melatonin is used widely to help initiate sleep in children. A recent randomised controlled trial demonstrated that melatonin brought sleep onset forward by an average of 20 min and prolonged sleep by an average of over 40 min.1 The cost of paediatric melatonin prescriptions in our Trust April – November 2010 was £231 236.38. (Extrapolated annual spend £462 472.76). As a part of our cost improvement processes, prescribing practices and charges were reviewed. The cost of melatonin to us from ‘community prescriptions’ (FP10) varied widely depending on the individual pharmacy charge, the formulation prescribed and brand of melatonin dispensed. There was no standard quality control process. Hospital pharmacists and clinicians produced a guideline for the prescription of melatonin in paediatric patients, rationalising the formulations and preparations available. Families were informed that melatonin would be prescribed only from the hospital pharmacy.

Families have been very co-operative with the new procedures. Issues arose in the first few weeks due to a significant shortage of melatonin in stock relative to the amounts of melatonin being prescribed. One batch of melatonin 3 mg MR capsules (imported from the USA) contained 5.6 mg of melatonin. This product is not required to meet pharmacopeial standards and, unlike melatonin capsules supplied within UK, does not have an upper limit for actual value. Following discussion, the decision was made to stop using this product. Patients are managed on the standard release capsules and licensed 2 mg MR tablets (circadin) alone. Following implementation of inhouse melatonin dispensing the total spend on melatonin for January to March 2011 was £52 506.64. The predicted annual expenditure is therefore £210 026.56 (cost saving £252 446.20 per year).

The centralised prescribing of an unlicensed medication has rationalised prescribing practice and ensured quality control procedures. It has allowed the development of a database allowing easier monitoring and audit of prescribing and is projected to result in significant cost savings. Learning points from the process include the importance of Accurate estimation of the likely monthly demand – perhaps by auditing prescribing practice of all clinicians for one month prior to implementation in order to gain a baseline. Clear identification of each stage in the ‘prescription pathway’ – from the family requesting a prescription to collecting the medication. Proactive communication to all pharmacy staff about the reasons for change, so families are given consistent information. This experience is being used to inform the centralisation of prescribing of other ‘specials’ within our Trust and may be extrapolated to similar services within other Trusts.

A 2007 NPSA report states that patients being given medicine to which they were known to be allergic accounted for 3.2% of all medication incidents reported; 33% of these resulted in harm and 5% in severe harm or death.1 It follows that where allergy status is not documented, the risk of harm to the patient is higher and therefore Trust standards require that 100% of drug charts have the allergy status documented before any medicine is prescribed or administered.2 3 Prospective data collection took place 1 day each week over a 10 week period from March 2010, and again from July 2011. Data were collected on Monday mornings before the pharmacist had been to the ward as it was assumed that the pharmacist would ensure 100% completion. Data were also collected relating to whether the chart had been seen at any point by a pharmacist. The new inpatient drug chart was launched at the end of 2010. It includes a cut out window on each page so that the allergy status can be seen on every page and the lines in the allergy box were removed to create more white space and counter the cluttered appearance of the previous drug chart. Feedback from the first audit was presented at the departmental audit meeting on the 5th July 2010. All data were analysed using Microsoft Excel.

2010 results: 280 (80%) of 350 charts were seen over a 10 week period. Of these, 84 (30%) did not have the allergy status documented. Of the 280 charts analysed, 134 (48%) had been seen by a pharmacist and 8 (6%) of these still had no allergy status documented. 146 (52%) of charts had not yet been seen by a pharmacist and 37 (25%) of this group had no allergy status documented.

The standard of 100% was not met; even after pharmacist screening. Awareness needs to be raised concerning allergy status and documentation thereof. It should be an integral part of the prescribing and screening process to ensure safe delivery of medicines. It is hoped that the changes to the drug chart will have improved the documentation.

The standard used incorporated local and national advice. At least one of the following criteria had to be met for a course to be ‘appropriate’:

Data were obtained from the Centralised IV Additive Service and dispensary records of all doses of meropenem prescribed for inpatients from 1st November 2009 to 1st November 2010. Case notes and medication charts for each patient identified were located to gather information regarding the indication and microbiological findings.

102 courses of meropenem were prescribed for 62 patients during the 12 month audit period (seven courses were excluded due to being initiated at other Trusts). 70 courses (68%) were found to be compliant and 32% were found to be non-compliant with the audit standards.

It is concerning that meropenem use is not adequately controlled by existing guidelines (in the case of septicaemia, where use of meropenem is widespread), by ID recommendation or by the presence of ESBL-producing or multi-drug resistant pathogens. Recommendations to the Trust are to add meropenem to the list of restricted drugs and educating pharmacists to challenge inappropriate use of carbapenems, thus limiting injudicious use.

To assess whether choice and monitoring of antibiotics prescribed for febrile neutropenia follow Trust guidelines.

A retrospective audit was conducted of consecutive patients admitted to the ward. Patients were included if they experienced an episode of febrile neutropenia. Prescribing was audited against the following standards; Standard One: patients prescribed piperacillin/tazobactam and gentamicin for their first febrile neutropenic episode. Patients with penicillin allergy or those with recent culture positive infection sensitive to agents other than piperacillin/tazobactam and gentamicin were excluded from this standard. Standard two Gentamicin trough level taken before second dose, then twice weekly (stat doses excluded). Standard three Vancomycin trough level taken at 24 h, then twice weekly (treatment less than 1 day excluded).

17 of the 21 patients met the inclusion criteria. Standard one: 14 of the 17 patients received piperacillin/tazobactam plus gentamicin as first line therapy. Alternative antibiotics were prescribed due to penicillin allergy, renal impairment and microbiology advice. Therefore overall compliance with the standard was 88%. Standard two: 16 courses of gentamicin were prescribed. Trough levels were measured before the second dose for 15 courses (94%). For the nine courses that continued, trough levels were taken at least twice weekly. All levels were within range with the exception of one patient with renal impairment. Standard three: 12 patients received a course of vancomycin. A trough level was taken at 24 h for 10 patients (83%). Levels were monitored at least twice weekly for all patients who continued vancomycin, although 32% of all levels were subtherapeutic (<5 mg/l).

The choice of initial antibiotics was generally in accordance with BMT guidelines. Alternative antibiotics were prescribed due to renal impairment and microbiology advice, which are reasonable exceptions. Gentamicin was monitored appropriately. Vancomycin dosing could be optimised as a third of levels were subtherapeutic, risking treatment failure and resistance. This will be disseminated to BMT consultants with a proposed review of vancomycin dosing.

A retrospective audit of 49 once daily tobramycin courses in 15 patients (5 male; 10 female) was undertaken during 2010. All patients were under the care of BCH and had received two or more courses of intravenous antibiotics including tobramycin. Data were collected from patients' hospital records recording; patient height, weight, dosage and time of administration, drug plasma levels, urea and electrolyte levels.

The median number of courses for the population reviewed per patient was three. Once daily tobramycin was administered at a mean dose of 9.94 mg/kg (n=49, range 8.8–11.0) which conforms to current BCH guidelines. At least one trough level was observed for every course (mean=1.33; n=49). Trough levels greater than 1 mg/l were seen in 17% (n=11/65) of samples, 27% (n=3/11) of these were >2 mg/l. In reporting of trough levels 63% (n=41/65) had no reference range quoted and 37% (n=24/65) had incorrect ranges. Tobramycin was administered after 3 pm in 97% (n=39/40) of courses administered and 23% (n=9/40) were after 9 pm. Only 39% (n=19/49) of courses had renal function and electrolytes recorded on the admission which differs from practice elsewhere in the UK. However, almost all patients (98%; n=48/49) had renal function and electrolytes monitored in the last year which is an accepted standard. It was also observed no patients underwent routine monitoring for ototoxicity.

The monitoring of tobramycin in CF patients varies within the UK. Current practice at BCH with regard to the dosing of once daily tobramycin and the timing of the first trough level are consistent with available guidelines. However an improvement in presentation of trough results would be desirable to ensure no risk of misinterpretation. The monitoring of renal function annually is in line with the UK CF Trust's recommendations but does differ from other CF centres and guidelines where creatinine levels should be taken at least once within a 14 day course.1 Current audiology arrangements need to be reviewed to ensure at risk patients receive appropriate monitoring. In this study a significant proportion of courses were administered in the evening which may result in an increased risk of toxic effects, due to a potential decrease in glomerular filtration rate. Further research is currently been undertaken in this area.

To address the rise in paediatric prescribing errors reported in March and September (six errors/month, compared with an average of 2.2 errors/month throughout the year), which coincides with the arrival of new doctors, a practical pharmacy induction session was introduced. The format and concepts from the Imperial College Healthcare NHS Trust Mandatory Medicines Management Training module1 were used, together with the London Deanery paediatric safe prescribing presentation.2 A senior paediatric pharmacist and two senior paediatric trainees designed the session, a fictitious case scenario. Doctors were given copies of the local drug chart, and a BNFC, and asked to prescribe the medication required. The case covered important prescribing principles, such paediatric prescribing, drug interactions and the prescribing of fluids. Charts were identified by the doctor's name, and were collected for review and marking. This allowed an introduction to the local drug chart as well as individual doctor assessment. A feedback questionnaire was sent to participants after the session.

22 doctors attended the session. Any incorrect, illegible or unclear prescriptions were identified. Only 2/22 (9%) of prescriptions had no errors; two major problems were identified. First, 11/22 (50%) intravenous aciclovir prescriptions were incorrect, due to wrong selection of dose and failure to identify the dose increase required in immunocompromised patients. Second, 13/22 (60%) of doctors prescribed intravenous fluids unclearly. In 11/13 (85%) cases, there was no documentation explaining the fluid calculation, resulting in an unclear instruction regarding infusion duration. There were two drug charts with a number of errors. A consultant spoke to these individuals separately, and they were given additional training. An email was also circulated to the department giving feedback from the session. Of 13/22 (59%) responses to the questionnaire, 12 (92%) felt the session had been helpful and 11 (85%) felt it was valuable to have both doctor and pharmacist input. 5/13 (39%) doctors had participated in similar prescribing exercises of which 3/5 (60%) included a written test. 12 (92%) felt it was useful to have the introduction to the local drug chart, and that it was useful to teach the prescribing of intravenous fluid; 7 (54%) felt the session had subsequently improved their prescribing.

The pharmacy induction session offered a good opportunity to improve the prescribing of new doctors starting at the Trust. It covered a number of paediatric prescribing principles, introduced local prescribing stationary and was well received by participants. The assessment of individual doctors meant that additional support could be given early where needed. Future audits will assess the error rate over the next few intakes of junior doctors to see if the number of reported errors decreases.

To create a care pathway for the medicines management and education of patients with asthma or viral induced wheeze in line with national priorities and to assess effects on patient care.

A baseline audit was undertaken to determine:

A care pathway was devised and implemented using improvement methodology techniques, these included:

Baseline audit data included 31 patients. 48% of patients had an accurate medication history documented on admission. 29% of patients had brought in their own inhalers. 45% of admitted patients were on a steroid inhaler prior to admission. 62% of patients had inhaler therapy checked within 24 h of admission. 94% of caregivers stated that they had been shown how to administer inhalers at the start of therapy (range between 1 month and 5 years). This initial demonstration had been by a variety of care providers. 84% of patients had their condition managed by their general practitioner. Postintervention data collection currently underway.

The baseline audit identified that medicines reconciliation was not being undertaken for patients. It highlighted areas of improvement for health literacy regarding inhaler administration and disparities of education provided by the nurses in the paediatric unit. Improvement methodology techniques require continual data collection and the real impact of the interventions made will only become apparent over time.3 The authors hope to see this through improved local BTS audit results, reduced admissions from poor control due to poor inhaler technique, less time spent on education by nurse specialist, use of PODs to aid drug history and reduced harm to patient with accurate medicines reconciliation, as well as a positive financial impact as a result of use of PODs.

Actual costs of hospital led supply of unlicensed medicines (including drug costs, delivery costs and service charges) were compared with estimated costs for the same or equivalent regimens recently provided through the usual primary care supply route (general practitioner (GP) prescription dispensed by community pharmacist). Items were supplied under a novel service level agreement between Birmingham Children's Hospital (BCH) and Birmingham East and North (BEN) PCT for unlicensed medicines. The hospital led supply pathway includes GP referral to BCH Pharmacy who determine which unlicensed product is to be dispensed at an agreed price. This is then dispensed and delivered by a community pharmacy partner. Supply was authorised using a patient specific direction signed by a registered prescriber. Estimates of primary care costs were provided by BEN-PCT using recent ePACT data of equivalent dispensed items, or average costs of the item and quantity from a composite database of 22 PCTs.1 Estimated primary care costs include net ingredient costs and dispensing fees as reported on ePACT. Data were entered into MS Excel 2007 for analysis.

A total of 67 items were provided under the scheme during the period 15th December 2010 to 25th March 2011. All items were unlicensed medicines in the UK identified by the patient's GP as suitable for the hospital led service. A total of 25 different formulations were supplied (19 different chemical entities). Savings per item ranged from minus £79 (a loss, Sodium Chloride 1 mmol in 1 ml solution) to £1 621.12 (Sildenafil liquid 25 mg in 5 ml). A total of £23 238.39 was estimated as the saving to the PCT, an average of nearly £350 per item supplied. The total cost of the supply for all 67 items via the scheme was £7 144.92 (£106.64 per item). This cost included drug costs, dispensing fee, delivery costs plus a service charge by BCH and was re-charged to BEN-PCT.

This study identifies for the first time drug related financial benefits of hospital led supplies of unlicensed medicines for children at home and supports this proposed innovation in National health service (NHS) processes.2 Some PCTs are known to spend more than £500 000 per annum on unlicensed medicines and therefore there is potential for large savings to the NHS.3 Further studies will be required to identify if this level of benefit is generalisable to other populations. It is acknowledged that this study only presents results for a relatively small population; multisite studies of this new innovation and related services, are in preparation.

Doses of 250 mg vancomycin (50 mg/ml–500 mg vial dissolved with 9.6 ml water for injection) were nebulised via both nebuliser systems. Particle size distributions were measured using a HELOS KF particle sizer (Sympatec, Germany) at four different flow rates (representing inhalation) ranging from a low flow rate (10.4 l/min) more representable of a patient with impaired lung function to a high flow rate (40.0 l/min) to study the impact of flow rate on the nebulisation process. The percentage of drug remaining in the residual volumes was calculated by measuring residual volume and concentration. Sample stability and residual volume concentration were evaluated by high-performance liquid chromatography.

Pari LC Plus nebuliser – average median particle sizes ranged from 2.37–2.55 μm across the four flow rates with an average median particle size of 2.52 µm at the lowest flow rate (representing people with impaired lung function). The percentage of particles produced in the respirable range (particles between 1–5 μm) ranged between 65.99–75.92%. Of the 250 mg dose nebulised, between 26.26 and 46.65% was retained in the nebuliser. The residual concentration showed a slight increase which ranged from 52.9 mg/ml to 56.87 mg/ml across the four flow rates compared to 50 mg/ml at initiation. No degradation was detected after nebulisation of vancomycin injection. eFlow rapid nebuliser – average median particle sizes ranged from 2.93–3.64 μm across four flow rates with an average median particle size of 2.93 µm at the lowest flow rate (representing people with impaired lung function). The percentage of particles produced in the respirable range (particles between 1–5 μm) ranged between 68.80–77.29%. Of the 250 mg dose nebulised, between 17.87% and 25.06% was retained in the nebuliser. The residual concentration after nebulisation ranged between 44.68 mg/ml and 44.35 mg/ml for the three lower flow rates with the highest flow rate showing an increase in residual volume concentration to 64.61 mg/ml. The concentration before nebulisation was 50 mg/ml. No degradation was detected after nebulisation of vancomycin injection.

Both the Pari LC Plus and eFlow rapid effectively nebulise vancomycin injection with more than 65% of the particles produced being in the respirable range. As also reported in literature, the eFlow rapid nebuliser has a smaller residual volume of solution remaining which impacts on the dose nebulised available for inhalation.1 The characteristics of the inhalation do vary depending on the nebuliser selected, but it is not known whether this is clinically significant.

A literature search was performed in MEDLINE, EMBASE and PUBMED up to 2010. Criteria for inclusion in the review were (1) studies that used assessment tools for evaluating the prescription of medicines, (2) adults or children, (3) hospitals or primary healthcare, outpatients or inpatients.

36 studies were found, involving 24 countries. 26 were carried out in low and lower middle income countries and only five in high income countries. 22 studies evaluated prescription medicines using WHO and International Network for Rational Use of Drugs (INRUD) indicators.2 These consisted of three types of indicators: (1) prescribing, for example number of drugs prescribed per consultation; (2) patient care for example mean consultation time, (3) health facility, for example availability of medicines from essential drugs list. All 22 studies were conducted in low income countries. Eight studies used modifications of the WHO and INRUD indicators. Five studies used their own guidelines or other criteria for assessing prescription medicines. One study evaluated prescription medicines by using the Essential Drug List. There were only four studies that involved children.

Most studies used WHO and INRUD indicators in evaluating prescription medicines and were carried out in low income countries. There have been relatively few studies in high income countries or in children. There is a need for better assessment tools to evaluate whether medicines are used rationally.

Case notes, prescription and administration charts were reviewed retrospectively for 20 patients receiving chemotherapy during April 2011. Prescribing of chemotherapy and antiemetics over the previous 12 months was recorded and adherence to guidelines assessed. Recently implemented patient sickness diary cards completed by patients/carers on each cycle of chemotherapy were evaluated. Prescribers' views and awareness of the guidelines were gathered from a specifically designed self-administered questionnaire. Outcomes from the study were presented at a multidisciplinary meeting where changes in practice were agreed.

Of the 20 patients (11 oncology; 9 haematology), 13 were male and ranged from 6 months to 19 years old. Five patients had received chemotherapy for longer than 12 months. Prescribing adhered to the guidelines greater than 70% of the time in eight patients, between 30–70% of the time in 10 patients and less than 30% of the time in two patients. Non-adherence trends were: unclear documentation of patients receiving prechemotherapy antiemetics, ondansetron continued longer than 24 h postchemotherapy to prevent acute nausea and vomiting, metoclopramide started concomitantly with ondansetron for prevention of delayed nausea and vomiting and lorazepam not being administered immediately post an acute emetic episode. Non-adherence was justified when there was a previous adverse reaction to an antiemetic or when emesis continued despite appropriate management and/or confounding circumstances such as parenteral nutrition. Omissions from the guidelines were use of aprepitant in teenagers receiving cisplatin-based regimens, emetogenic risk of clofarabine and intrathecal cytarabine and guidance on evaluating emetogenic risk for investigational medicinal products such as chimeric 14.18/CHO monoclonal antibody (antiGD2). Five patients returned completed Patient Sickness Diary Cards. Excluding one patient with low-grade glioma and pre-existing vomiting prior to chemotherapy who experienced 13 vomits over a 5 day reporting period, only three vomits were noted over a total of 36 days reported but 22 patient days (61%) were recorded as nauseated. 17 out of 35 (49%) prescriber questionnaires were returned. Prescribers reported awareness of the guidelines and considered them helpful. The patient specific antiemetic record was not used, and there was multidisciplinary agreement that working practices be reviewed to facilitate accessibility.

The revised guidelines are mostly adhered to and the results have informed where adjustments and additional information are required. The patient diary card and the patient specific antiemetic record were considered useful in the individualisation of treatment and are to be integrated into working practices and used for continuous quality monitoring.

The study instrument was non-participant, direct observation of a discrete, clearly identifiable step within the dispensing process (the accuracy-checking phase of the dispensing process). A prescription requiring two bottles of medicines to be dispensed was created. The medicines were labelled and placed in a tray together with the required paperwork, additional spoons or oral syringes and a dispensing bag. The operatives, both pharmacists and pharmacy technicians, volunteered to participate and were told that they would be timed accuracy checking a prescription and that the object of the observations was to measure the impact of the environment on their work only. That is they themselves were not being assessed. They were also advised that the prescriptions were non-complex, had been clinically screened, and did not contain any errors by design. Each observation (n=34) consisted of two arms as determined by a Latin square. A Latin square ensures that all possible variants are carried out. The observations were undertaken in the dispensary and in an office; the later ensured a quiet environment. In addition a designed interruption was introduced into some of the variants. The interruption consisted of the operative being stopped during the observation and asked to check a dose calculation. Each observation and each interruption was timed and recorded in MS Excel 2007. The variants consisted of accuracy checking the prescription: in the dispensary, in the office, in the dispensary with an interruption and in the office with an interruption.

SPSS (IBM) statistical software was used to test for the null hypothesis which showed that there was a significant difference (p<0.05)between the median of the time taken to accuracy check an item in the dispensary with interruption to accuracy checking an item in a sound controlled environment without interruption. When interrupted an operative took longer to accuracy check the prescription. The mean additional time it took when an interruption had occurred in the dispensary when compared with the quiet office without interruption was 33.15 s or 27% longer. One third of operatives took up to 103 s longer to carry out a standard task, one third took up to 40 s longer and one third took up to 25 s longer when compared to non-interrupted observations.

It was found that interruptions impacted adversely on dispensary accuracy checkers who were checking a standardised prescription of two items in the dispensary at BCH. Efficiency of the accuracy checking process was shown to reduce by up to 78% or 103 s. Dispensary design should support the reduction of interruptions in critical areas.

Data collection took place over a 2 week period in May 2010 and a second 2 week period in January 2011. EDC version 2 was implemented in late summer 2010. Discharged patients were identified from daily medical handover summaries. Drug charts and medical notes were obtained to identify new and changed medicines. The EDC was reviewed to identify if changes were clearly documented for the general practitioner. All data collection forms were reviewed by a senior pharmacist for quality assurance. Bone Marrow Transplant, oncology, HIV patients and inter-hospital transfers were excluded.

During the initial data collection period, 89 children were discharged. Only 62 (70%) of these patients had a discharge summary. This rose to 97% (114 of 117) in the second period. In the initial period there were 22 patients with medicine changes, but only 8 (36%) had complete documentation on the EDC of the reasons behind the changes. In the second period, 42 patients had medicine changes, with 27 (64%) having the reasons fully documented. In the initial period there were a total of 72 medication changes for the 62 patients with EDCs, 59 of which were new medicines started. Only 24 (33%) of all medicine changes had the reason documented. In the second period there were 66 medication changes for 114 patients with EDCs, 17 of which were new medicines started. Of the 66 medication changes, 38 (58%) had the reason documented.

The initial audit results raised the profile of EDC within the paediatric medical team. Prior to EDC version 2 the CQUIN target was not met, however EDC version 2 has been successful in significantly increasing the number of children who get an EDC at the time of discharge. It has also been successful in increasing the number of patients (and corresponding drugs) with documentation relating to changes made. However more work needs to be done to achieve the current target of 80%. A suggested system change would be to make the indication field mandatory.

Prescriptions for liquid medicine for inpatients were reviewed over five weeks at two hospitals in the North West of England in January/February 2011. Patients on Neonatal and Paediatric Intensive Care units and children's wards were considered for study. Date of birth, name, strength and prescribed dose of drug, the volume to be administered and whether that dose was measurable using a single syringe were documented. The volume required to administer each dose was calculated from the prescribed dose using the concentration of the formulation available on the ward. A dose was considered measurable if the volume required could be measured using the smallest single syringe. Analysis of the data by SPSS involved frequency statistics.

1599 liquid doses for 431 patient records were reviewed. 196 liquid doses (12.3%) were immeasurable. Of these immeasurable doses, 29 (14.8%) related to neonates, 58 to infants (25.6%), 81 to children (41.3%) and 28 to adolescents (14.3%). Syringes used for immeasurable doses ranged from 1 ml to 60 ml, 1 ml syringe accounting for 25% (49/192) immeasurable doses; 2.5 ml syringe 28.6% (55/196), 5 ml syringe 22.5% (44/196), 10 ml syringe 16.8% (33/196) and syringes ≥20 ml 7.7% (15/196). Medicines that were deemed immeasurable included those for infection (eg, cefradine, ceftazidime, gentamicin, metronidazole) 34.2% (67/192) and analgesia (eg, paracetamol, ibuprofen and diclofenac) accounted for 25% (49/196). Others medicines included antiepileptics (3.6%, 7/196) for example phenytoin and phenobarbital; corticosteroids (10.7%, 21/196) for example dexamethasone and hydrocortisone; GI medicines (9.2%, 18/196) for example rantidine, domperidone and ondansetron and sedatives (5.1%, 10/196) for example chloral hydrate and diazepam.

The study found that one in eight prescribed doses of liquid medicine for children and neonates cannot physically be measured. The measurability of prescribed doses of medicine must be addressed. Ideally this consideration should take place at the time of prescribing or be reviewed by the pharmacist prior to administering the first dose. Resolving the widespread problem of immeasurable doses is complicated by the fact that concentrations of medicine vary widely. For example 24 mg of paracetamol liquid is sensible and can be measured. However 5 mg of dexamethasone is immeasurable and would better be prescribed as 4.95 mg? Further research to explore the measurability of doses of liquid medicines and the relationship with medicines that have a narrow therapeutic window should be undertaken.

The authors wished to study the children of asylum seekers and refugees in the East Midlands area of the UK, as they are thought to be likely to experience significant problems in accessing healthcare and medical treatment.

Semistructured interviews were conducted with parents of these groups of children. The authors determined accessibility to healthcare and also their attitudes towards receiving treatment for the following medical conditions: epilepsy, asthma and pain. The authors recorded medicines given to the children by parents over the last month and the last 6 months. Difficulties in relation to obtaining medicines were explored.

The authors interviewed 46 refugees and asylum seekers. They had a total of 111 children (median number 3, range 1–6). The ages of the children ranged from 2 months to 18 years (median age 6 years). All were registered with GPs and all children were fully immunised. 31 children had had an illness in the preceding month and all were prescribed a medicine. A total of 43 medicines had been prescribed. The number of medicines prescribed range from 1 to 3 (median 1). Ninety seven children had had an illness in the last six months and 81 were prescribed a total of 89 medicines (median number 2, range 1–3). The medicines prescribed included paracetamol, ibuprofen, amoxicillin, digoxin, lisinopril and lactulose. Twenty parents stated that would give analgesics for earache, whereas 26 would not. Thirty four would be happy to inform their friends and relatives that their child had epilepsy whereas 12 would not.

This pilot study suggests that access to medicines and healthcare in children of refugees in the East Midlands is good. Further work is underway with large numbers to provide more information.

An audit form was designed and the audit was conducted by a medical student. The study period was between 1st July 2009 and 31st May 2010. A retrospective study, that included all the paediatric congenital heart disease patients, maintained on warfarin, via near point testing in the community, who were dosed by the paediatric cardiac team. Patients were identified from the cardiac database (Heartsuite) and the anticoagulation records. Standards were taken from the NPSA Alert 18 safety indicators and included; the number of INRs measured, percentage within range, numbers greater than INR of 5 and 8 and INRs less than one unit below target range. The audit also reviewed major bleeding episodes and annual review at an anticoagulation clinic.

50 patients were identified. The median age was 10 years (range: 8 months to 18 years). The indications for warfarin were varied and included fontan circulations, mechanical valves, thromboembolic events, cardiomyopathy and other surgical indications. The majority of patients had INRs at the recommended time intervals. Two thirds of INRs were within target ranges. There were only three children with an INR greater than eight but there were no episodes of major bleeding. There were no serious adverse events; all patients had a target INR documented in their medical case notes.

Anticoagulation with warfarin in the paediatric population is challenging due to intercurrent illness, childhood development and concurrent medication contributing to variations in bioavailability and hence changes in INR. The NPSA recommendations were driven by the need for safe anticoagulation in the adult population on long-term anticoagulation monitored in community. They are not flexible enough to accommodate the very different prospect of safely anticoagulating a child with complex congenital heart disease. The results demonstrate that home INR monitoring with proper education and liaison provides a safe and effective treatment option for cardiac children requiring warfarin. This is especially important for our geographical area in the South-West and perhaps is a model that could be used in other regions.

The study involved infants who required treatment with vancomycin during their admission to the neonatal intensive care unit at Yorkhill Hospital, Glasgow, between March and June 2011. During the first month, intermittent vancomycin (Ivanc) infusion was started, at a dose of 10, 15 or 20 mg/kg over 1 h every 12 or 8 h, according to creatinine concentration. Thereafter, doses were adjusted to maintain troughs of 12–15 mg/l.1 Ivanc dosing was maintained in month 2 while staff received training on the continuous vancomycin (Cvanc) infusion guidelines, which comprised of a loading dose of 15 mg/kg followed by a continuous infusion of 20–60 mg/kg/day according to creatinine and corrected gestational age (CGA). Doses were adjusted to maintain concentrations of 15-25 mg/L. These guidelines were implemented in month 3. During months 1 and 4, the following data were collected: age; weight; date, time and dose given; vancomycin concentrations; creatinine concentrations at the start and 2 weeks after therapy. Clinical characteristics were compared by t-test and concentrations by ² test.

There were 20 courses (15 patients) of Ivanc infusions and 20 (17 patients) of Cvanc infusions. There were no differences in CGA (mean±SD 37.6±4.8 weeks Ivanc versus 38.7±2.7 weeks Cvanc) or weight (2.39±0.95 kg versus 2.66±0.82 kg) between the groups. Mean±SD vancomycin concentrations were 13.3±3.9 mg/l (Ivanc) and 21.7±4.6 mg/l (Cvanc). The first concentration was within the target range in 45% of the Ivanc and 75% of the Cvanc courses. Although similar proportions were above the target ranges (20% and 25% respectively), low concentrations were only observed in the Ivanc group (35%). Overall, 34% of 50 samples were within the target range in the Ivanc group and 77% of 82 in the Cvanc group (p=0.0001; CI₉₅ 0.24 to 0.58). The starting dose was correct in 80% of patients in the Ivanc group and 95% in the Cvanc group. In the Ivanc group, 51 doses (18%) were administered >30 min outside the prescribed time; no administration problems were identified in the Cvanc group. In the Ivanc group, eight patients had at least one dose change and two had >3; in the Cvanc group, 10 patients had at least one change and none had >3. Creatinine concentration did not increase in either group.

The results suggest that continuous vancomycin infusion in neonates is more likely to maintain concentrations within the target range compared to intermittent vancomycin infusion. In clinical practice, the continuous administration schedule helps to minimise errors with dose times and associated monitoring inaccuracies.

The EQUIP data collection forms are used on one day per month to record any prescribing errors identified according to defined criteria. Data are collected on all new items prescribed, the prescribing stage (for example admission, during stay or discharge), the grade of prescriber and whether an error occurred. Full details of the actual error are recorded on a second form and the pharmacist allocates a potential severity according to predetermined criteria. Unfortunately an error validation panel similar to that used in the EQUIP study was not possible but one senior clinical pharmacist assessed all errors to establish validity and check the severity grading. This report includes all errors identified through this methodology during 2010.

Over the 12 data collection dates in 2010 a total of 3994 items were checked. 340 errors were detected, giving a mean error rate of 8.5 per 100 medication orders. This compares with a mean error rate of 8.9 per 100 medication orders in the EQUIP study. Similarly to the EQUIP study, The authors found that the grade of prescriber responsible for the highest rate of prescribing errors was the Foundation Year 2 doctors (11.3% Alder Hey, 10.3% EQUIP) and that FY1 produced a lower rate of prescribing errors (7.4% Alder Hey, 8.4% EQUIP). The most frequent error type in paediatrics was dosing errors which accounted for 26.8% of all errors. Omission of medication was found to occur in 12.6% of cases. This is in contrast to the EQUIP study which found that omissions accounted for 36% of errors and dosing errors 19.6%. Four errors (1.2%) were assessed as being potentially lethal, 18 (5.4%) as serious and 126 (37%) as significant. The EQUIP study found 1.7% of errors were potentially lethal, 5.6% serious and 53% significant.

This study has shown that although the overall frequency and severity of errors in paediatrics are very similar to those in a mainly adult population, the types of errors are quite different. This information has been used locally to inform the content of tutorials and assessments so that prescribers are aware of common paediatric prescribing problems.

A systematic review of qualitative studies was conducted that explored the experiences of children on dialysis. Electronic databases and reference lists of relevant articles were searched to October Week 2, 2010.

A total of 17 studies, which reported the experiences of 143 children receiving dialysis, were included. Five major themes were identified: loss of control (high reliance on carers, parental overprotectiveness, unrelenting dependence on a machine, impaired body integrity), restricted lifestyle (limited socialisation opportunities, academic struggle), coping strategies (hope for kidney transplant and medical advances, social support, positive determination and self-awareness, engaging in activities, denial), managing treatment (ownership, proactive involvement, adherence to fluid and diet restrictions) and feeling different (abnormal physical appearance, injustice, being a burden).

Children undergoing dialysis experience impaired growth, invasive procedures, school and social constraints. They often have poor self-esteem and a pervasive sense of losing their identity, body integrity, control, independence and opportunity. Interventions are needed to equip children with the capacity to manage their health, participate in community, engage in ‘permissible’ recreational activities, progress in their studies, and remain vigilant in dialysis and treatment responsibilities, for improved health and treatment outcomes.

Tertiary paediatric endocrine centre.

Retrospective evaluation of 14 male patients with partial androgen insensitivity syndrome (PAIS) with verified androgen receptor (AR) mutations. The authors recorded phenotypic characteristics at birth and external masculinisation score (EMS), registered longitudinal growth, circulating levels of testosterone, estradiol, luteinising hormone (LH), follicle-stimulating hormone (FSH), inhibin-B and sex hormone binding globulin (SHBG), in addition to phenotype at postpubertal follow up.

The EMS ranged from 5 to 12 in PAIS at birth. Six patients were born with hypospadias and all patients developed gynaecomastia in puberty. Eight of the patients received testosterone treatment. At follow-up penile size was impaired irrespective of EMS at birth, but responded to pubertal androgen therapy in some of the patients. Serum levels of testosterone, estradiol, SHBG and LH, but not FSH and inhibin B, were markedly elevated in puberty. Final height was 181.3 cm (165.7–190.5 cm) corresponding to an SD score of 0.7 (–2.1 to +2.1 SD, n=10).

Gynaecomastia and impaired phallic growth are frequently observed in adults with PAIS, but may be ameliorated by androgen therapy. The authors suggest that male patients presenting with gynaecomastia in puberty, and elevated circulating levels of testosterone, estradiol and LH in puberty, but normal FSH, should be suspected of having PAIS and undergo genetic testing for AR mutations.

To examine associations between the number of hospital admissions for bronchiolitis and pneumonia and elective caesarean delivery.

Retrospective population-based data linkage cohort study of 212 068 non-Aboriginal singleton births of 37–42 weeks gestation.

Negative binomial regression was used to examine associations between mode of delivery and hospitalisations for both bronchiolitis and pneumonia in children aged <12 months and 12–23 months. Models were adjusted for obstetric and known risk factors.

16% of children were delivered by elective caesarean section (n=33 421). In adjusted analysis, compared with spontaneous vaginal delivery, these children had increased risk of admissions for bronchiolitis at age <12 months (incidence rate ratio (IRR) 1.11; 95% CI 1.01 to 1.23) and 12–23 months (IRR 1.20; 95% CI 0.94 to 1.53) independent of other fetal and maternal factors. There was no association between elective caesarean delivery and number of pneumonia admissions aged <12 months (IRR 1.03; 95% CI 0.80 to 1.33) and 12–23 months (IRR 1.09; 95% CI 0.88 to 1.34).

Delivery by elective caesarean was independently associated with infant admissions for bronchiolitis but not pneumonia. Elective caesareans or delivery without labour may result in impaired immunity in the newborn leading to increased risk of early viral lower respiratory infections.

Using four retrospective audits over a 10-year period, the authors examined the change in practice and maintenance of that change following a targeted implementation program for the clinical guideline.

Tertiary children's hospital in South Wales.

447 children aged less than 5 years, admitted to hospital with acute gastroenteritis, comprising four cross-sectional samples (106 in 1999, 153 in 2002, 99 in 2004, 89 in 2009).

Age of child, hydration status, method of rehydration and duration of admission, for each audit, with an implementation strategy delivered after the second audit.

In 1999 and 2002, intravenous rehydration was used in 20% and 15% of cases, respectively. After the implementation program in 2004, compared to 1999, there was a significant decrease in the intravenous rehydration rate to 4% in 2004 (p<0.001); in 2009 the intravenous rehydration rate was maintained at a low level of 6% (p<0.001).

It was only after the implementation program that a change in practice was achieved. Once change had been accepted, it was maintained even in the absence of targeted training. Audit does not improve clinical practice unless, in addition, there is a clear, succinct guideline with an implementation programme in place.

To explore the variability in clinicians' interpretation of BMI patterns and to ascertain the diagnostic accuracy of their judgement by relating it to change in body composition by dual-emission x-ray absorptiometry (DXA).

Data from 70 children who participated in a trial of a weight management programme for obese children were analysed. BMI was plotted on UK 1990 charts at baseline, 6 months and 12 months, and four clinicians experienced in obesity management independently scored the charts on a five-point scale for how successful children were in tackling their obesity over a 6-month period. Scores were compared with change in BMI, fat mass and lean mass z-scores as measured by DXA.

54 children (aged 8–15 years; BMI z-score 2.93 (SD 0.48)) had simultaneous BMI and DXA scans performed, giving 104 pairs of measurements 6 months apart. There was good consistency between clinicians' scores for weight management and these related well to change in BMI and fat mass z-scores, but not lean mass z-score. They reported that measurement proximity to centile lines and crossing of lines influenced their confidence in making a decision and change in severe obesity was harder to judge as higher centile lines are so far apart.

BMI charts are useful for assessing children's attempts at weight management, and provide a reasonably accurate indication of change in body fat. Recommendations are made regarding BMI chart design and guidance in interpreting measurements.

All neonates born from June 1988 to December 2008 (inclusive) were included in the prospective cohort, with a minimum follow-up of 12 months. All underwent an early clinical examination of the hips and those with clinical instability were referred for ultrasound at 2 weeks; those with risk factors were sonographically examined at 6 weeks. Risk factors were defined as breech presentation, family history or foot deformity.

107 440 live births were clinically examined, 20 344 (18.9%) were referred for ultrasound assessment at either 2 weeks (due to clinical signs) or 6 weeks (due to risk factors). 774 (3.8%) were diagnosed with dysplasia with a crude overall treatment rate of 7.2 per 1000 live births. 37 (0.34 per 1000) presented late, that is, after 12 weeks of age; none had detectable clinical signs or risk factors. There were no false negatives.

Elective screening for developmental dysplasia of the hip in association with one stop treatment and monitoring is an effective programme. The number of infants referred increased statistically significantly year on year over the study period and generated more activity. Pavlik harness treatment rates remained acceptable and steady over the period, despite the increase in referrals. The incidence of late presenting cases ranged from 0 to 4 per year, with no secular trend and there were no ultrasound false negatives.

The last 5 years have been a particularly exciting time in diabetes medicine with dramatic implications for a few patients. There have been advances in our understanding of the genetic basis of disease, and furthermore, technological advances in monitoring glycaemic control and delivering insulin leading to significant changes in the provision of care to many children with diabetes. This article focuses on a few major discoveries in recent years that have impacted on the diagnosis and treatment of young people with diabetes attending my clinical service.

The diagnosis of diabetes is...]]> 2012-04-22T22:24:28-07:00 info:doi/10.1136/adc.2011.300710 hwp:master-id:archdischild;adc.2011.300710 BMJ Publishing Group Ltd 2012-05-01 Reviews 97 5 436 439 http://adc.bmj.com/cgi/content/short/97/5/440?rss=1 While prevention of iatrogenic harm is a sufficient priority to determine service structures and practice, the concept of harm is largely restricted to the physical. Psychological harm has received scant attention despite its importance, particularly for children and adolescents. A professional climate increasingly reliant on measurement and evidence and coloured by fear of litigation contributes to perpetuating the anomaly. The aim of this paper is to consider how and why iatrogenic psychological harm may happen, why i-dt matters, how it may be manifest and how it may be prevented. Prevention of psychological harm should be as great a priority as that of physical harm.

A 2-month-old infant presented with a 5-day history of...]]> 2012-04-22T22:24:28-07:00 info:doi/10.1136/archdischild-2011-300590 hwp:master-id:archdischild;archdischild-2011-300590 BMJ Publishing Group Ltd 2012-05-01 Case report 97 5 459 460 http://adc.bmj.com/cgi/content/short/97/5/461?rss=1 Objective

Opsoclonus-myoclonus syndrome (OMS) is a serious, often disabling neurological illness of early childhood which is frequently associated with occult neuroblastoma. As investigation methods vary significantly, the authors assessed the usefulness of imaging and metabolic studies in tumour detection.

Retrospective case note review of 101 OMS patients from two paediatric neurology centres over 53 years.

The prevalence of neuroblastoma in OMS was 8% in the 1970s, 16% in the 1980s, 38% in the 1990s and 43% in the 2000s, with tumours being mainly low grade. CT/MR imaging of the chest and abdomen was the most accurate test to detect occult neuroblastoma. Poorer sensitivities were noted for metaiodobenzylguanidine scintigraphy and urine catecholamines, reflecting the low metabolic activity of these tumours.

CT/MR imaging has the highest detection rate of neuroblastoma and this should be reflected in investigation protocols to achieve the best possible outcome for children with OMS.

Cross-sectional design.

Among 6381 children (median age 9.2 (7.7–10.7) years) with complete information on NS, 3225 were boys (50.5%). 747 children (11.7%) were reported to have weekly NS in the past 12 months. Boys were more likely than girls to have NS (p<0.0001). Children with NS were more likely to have sleep-related symptoms and respiratory and atopic diseases. In addition, they were more likely to be hyperactive and have frequent temper outbursts. Using an ordinal regression model, NS was found to be significantly associated with male gender, younger age, allergic rhinitis, tonsillitis and symptoms suggestive of obstructive sleep apnoea, insomnia and parasomnia.

NS is prevalent among school-aged children and is associated with the presence of sleep-related symptoms and respiratory and atopic diseases.

Prospective cohort study with 100% ascertainment.

Community.

117 consecutive cases of open spina bifida whose backs were closed non-selectively at birth. In 2007, all 46 (39%) survivors and/or carers were surveyed by postal questionnaires and telephone interviews.

Of the 38 children with absent sensation only below the knee (sensory level below L3), 23 (61%) survived of whom 14 (61%) were community walkers and only 5 (22%) needed daily care. But in 42 babies with absent sensation up to the umbilicus (sensory level above T11) only seven (17%) survived, none could walk and five (71%) needed daily care. Survivors with no shunt revisions were more likely to walk, live independently and drive a car.

Mobility and the need for care at 40 can be predicted from the neurological deficit.