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How do we ensure safe prescribing for children?
  1. Helen Sammons,
  2. Sharon Conroy
  1. Academic Division of Child Health (University of Nottingham), The Medical School, Derbyshire Children’s Hospital, Uttoxeter Road, Derby DE22 3DT, UK
  1. Sharon Conroy, Academic Division of Child Health (University of Nottingham), The Medical School, Derbyshire Children’s Hospital, Uttoxeter Road, Derby DE22 3DT, UK; sharon.conroy{at}

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Between January 2005 and June 2006 almost 10 000 medication safety incidents related to prescribing were reported to the UK National Patient Safety Agency, and over 80% of these occurred in hospitals.1 Children aged up to 4 years were involved in more than 10% of all incidents where age was stated, higher than the proportion of bed days they account for. This is likely to be an underestimate as it relies on a voluntary reporting scheme. However, the reluctance to report errors in the NHS is gradually changing as it is increasingly recognised that systems, not individuals, are usually to blame.

There has recently been debate in the medical press about the competency of medical professionals to prescribe. Aronson et al2 highlighted the fact that medical students and junior doctors may be unprepared for prescribing drugs when they qualify. Subsequent intense discussion led to a review by the General Medical Council (GMC) Education Committee of UK teaching and assessment of prescribing. This has prompted plans for research into the prevalence and causes of prescribing errors and recommendations about educational or ethical interventions to reduce them (see

A core curriculum for teaching safe and effective prescribing in UK medical schools has been described.3 This mentions children in two sections:

  • Core knowledge and understanding should include prescribing for patients with special requirements because of their altered physiology, pharmacokinetic handling or pharmacodynamic responses

  • Core skills should include prescribing drugs in special groups.

However, further detail is not provided in either section.

Children are not small adults when it comes to either drug development or prescribing. The availability of information to support paediatric prescribing practice has improved in recent years with moves from the use of a plethora of paediatric formularies and dose guides based on local practice, to the availability of a national, peer reviewed, evidence based reference source in the British National Formulary for Children. However, mistakes continue to be made in prescribing for both children and adults. We also have increasing numbers of non-medical prescribers, such as nurses and pharmacists, who are prescribing for children.


Children require drug doses calculated on an individual basis, taking into account gestational and postnatal age, weight and/or body surface area. Compared to the situation in adults, “standard” doses rarely exist. Drug selection and doses must account for children’s dynamic changes in pharmacokinetic and pharmacodynamic maturity and the potential for drug toxicity which can be different to that in adult patients. The need to use drugs which are unlicensed or off label for many children both in hospital and at home also means that suitable licensed products and prescribing information are not always readily available. Children are at higher risk of prescribing errors than adults and have fewer internal reserves to cope with them if they occur.4


There is a perceived reduction in the teaching of clinical therapeutics and prescribing at medical school. Traditionally medical schools taught “basic sciences” as a foundation for clinical training, but now many use a system of problem based learning of the curriculum. Guidance has been given from the GMC on the key learning objectives concerning the use of drugs for the management of disease ( This requires students to be able to calculate drug dosages and record the outcome accurately, and to write safe prescriptions for different types of drugs. Medical students however seem to feel less than confident in their ability to prescribe at the point of graduation from medical school. In a survey of F1 doctors, 68% did not agree with the statement “I was adequately trained to prescribe at the point of graduation”.5 Although there is a perception that prescribing errors may be traced back to inadequacies in undergraduate teaching, there has been little research to assess this.3

Teaching of junior doctors

Many UK paediatric departments run their own teaching sessions on prescribing for children. There has been little published regarding their format or content and most centres work independently without sharing resources or expertise. There are no central recommendations for either such teaching of new doctors or ongoing training of paediatricians. In our trust we run a 1 h teaching session for senior house officers (SHOs) within 1 month of their starting in paediatrics and a 2 h session for all F2 doctors within their teaching program. These sessions include a lecture on the differences between paediatric and adult prescribing, mention the importance of continued drug research, highlight risks of paediatric medication errors and provide examples of common mistakes. Scenarios are presented and the doctors are asked to practice prescribing on drug charts followed by a discussion. There is no formal assessment of individual doctor’s prescribing. At ward level, pharmacists and nurses play an important role in detecting and rectifying mistakes, and provide advice and support to medical staff in their prescribing practice. A study in our trust identified 139 clinical interventions by pharmacists and nurses to correct or clarify prescriptions in a 6-week study period.6

Assessment of competency

It is difficult to determine what impact our teaching has on prescribing competency or if it is typical of that throughout the UK. A Cardiff study looked at whether paediatric junior doctors given ideal circumstances would prescribe correctly.7 The study consisted of a test conducted during an interactive session for paediatric SHOs at induction. Only 31% (10/32) answered all four questions correctly. One doctor answered all four incorrectly. Experience did not improve prescribing skills, in fact it apparently did the reverse. Six of nine doctors with no paediatric experience answered all questions correctly compared to only four of 23 with previous paediatric experience. Other studies have suggested that clinical experience has little to do with making calculation errors, but that the necessary skills for calculations are obtained earlier in education.8 ,9 A national competency based assessment in prescribing for children/neonates has been recommended, which could be embedded within the postgraduate MRCPCH exam.7 It is difficult, however, to establish the best format and timing that competency assessment should take. Ideally practical paediatric prescribing should be addressed at all levels in medical education and competence to prescribe should be assessed BEFORE prescribing begins for real patients. In light of the above studies, training and validation of competency should then continue throughout a doctor’s career.

Canadian research examined the numeracy skills of 34 paediatric residents by anonymous testing.8 Seven trainees committed 10-fold errors in their calculations. There was no correlation between length of training and likelihood of making a mistake. Rowe et al recommended screening residents before starting paediatric practice to identify those who may need increased supervision and training. To our knowledge, few UK centres routinely do this, with most doctors just expected to start work in a new specialty and prescribe as necessary. Prescribing error rates have been seen to double when new doctors start work on paediatric wards.10 In comparison, nurses are required to pass a test prior to being allowed to administer drugs and pharmacy staff prior to checking dispensed items, although admittedly this may not necessarily guarantee competence. Mistakes in dispensing and drug administration are still common and less likely to be detected prior to reaching the patient as they are further down the medicines management pathway.

Further work

While the GMC research project into the prevalence and causes of prescribing errors in new doctors is welcomed, the challenges in paediatrics are specifically different to those in adults. It would be prudent to investigate further what measures are being taken currently for the teaching of paediatric prescribing in the UK and any assessment of competency that follows this. It is essential for our national organisations, such as the RCPCH and Neonatal and Paediatric Pharmacists Group, to become involved in the development of national standards. Electronic prescribing is anticipated by some to be the answer to all these problems and has been suggested to reduce prescribing error rates. However, it is proving to be a challenge to introduce it into the UK and with paediatric prescribing systems requiring even more complex support than those for adults it is unlikely to be widely available for neonates and children for some years yet.


The safety and well-being of the patient need to be the first concern of any healthcare professional, regardless of that patient’s age. Prescribing for children does however have its own specific challenges. Doctors entering the paediatric setting and those in training need therefore to have ongoing teaching and supervision. In the UK we have no formal training for prescribing, nor a validated tool for assessing the competence of prescribing in any age group. These are essential to avoid the regular errors which occur. If we are going to assess competency, we also need to have mechanisms in place to support failing prescribers. We will need mechanisms for reassessment in the future and resources to cope with the implications that this may bring if prescribers fail. These will be challenges for all paediatricians, pharmacists and other non-medical prescribers in the future.

Ways to improve prescribing practice and reduce medication errors

  • Supply rules regarding zeroes and decimal points

  • Provide drug monographs of high risk drugs

  • Pharmacist review of all prescriptions

  • Individualised emergency drug dose chart

  • Double checking and double signature on all calculations for hazardous drugs

  • Accurate patient history taking

  • Ready access to paediatric drug dosing texts

  • Removal of hazardous drugs not required on a stat basis

  • Medical student and doctor testing on drug dose calculation and prescribing

  • Dose calculation education for prescribers

  • Electronic prescribing systems with paediatric prescribing decision support

  • Preprinted prescriptions

  • Avoid calculations by use of standard doses/dose charts, etc

Examples of drugs with potential serious consequences if prescribed incorrectly

  • Aminoglycosides

  • Anticoagulants

  • Cytotoxic drugs

  • Digoxin

  • Insulin

  • Opiates

  • Phenytoin

  • Potassium chloride



  • Competing interests: None.