LICENSE STATUS OF DRUGS INVOLVED IN NEONATAL AND PAEDIATRIC MEDICATION ERRORS

S. Conroy. Academic Division of Child Health, School of Graduate Entry Medicine and Health, University of Nottingham, Derbyshire Children’s Hospital, Derby DE22 3DT, UK

Background: Use of unlicensed and off label drugs in children is common and leads to a number of well documented problems. This study aimed to explore whether there is a relationship between medication errors in hospital inpatients and the license status of the drugs involved.

Methods: Forms reporting medication errors in the Derbyshire Children’s Hospital from January 2004 to December 2006 were analysed in terms of the nature of the error and the license status of the drugs involved. This was compared to the expected license status of drug use on the wards.

Results: Unlicensed drug use in children was more likely to be associated with errors. It is estimated that 7% of all prescriptions on paediatric wards are unlicensed. Errors associated with unlicensed use however, ranged from 12% (prescribing) to 25% (dispensing) and were 17% overall. Unlicensed drug use in neonates was also more likely to be associated with errors. The error rate ranged from 26% (administration) to 83% (dispensing), with 38% overall, whereas unlicensed drug use in neonates is estimated to be only 10%. The risk of errors did not appear to be increased with the use of off label medicines. In children the error rate ranged from 4% (prescribing) to 25% (dispensing), with 10% overall, whereas off label drug use is estimated to be 23%. In neonates the error rate ranged from 17% (dispensing) to 43% (administration), with 38% overall, whereas off label drug use in neonates is estimated to be 55%. Twenty (13%) errors were considered to have caused moderate harm and 12 (60%) of these involved unlicensed and off label drugs.

Conclusion: Use of unlicensed drugs increased the risk of medication …