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Original research
Incidence of paediatric 10-fold medication errors in Wales
  1. Yincent Tse1,2,
  2. David Tuthill3
  1. 1Department of Paediatric Nephrology, Great North Children's Hospital, Newcastle upon Tyne, UK
  2. 2Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
  3. 3Department of Paediatrics, Children's Hospital for Wales, Cardiff, UK
  1. Correspondence to Dr Yincent Tse, Department of Paediatric Nephrology, Great North Children's Hospital, Newcastle Upon Tyne, UK; yincenttse{at}nhs.net

Abstract

Objectives To estimate the incidence, characteristics and outcomes of 10-fold or greater or a tenth or less medication errors in children aged <16 years in Wales.

Design Population-based surveillance study July 2017 to June 2019. Cases were identified by paediatricians and hospital pharmacists using monthly electronic Welsh Paediatric Surveillance Unit (WPSU) reporting system.

Patients ‘Definite’ incident occurred when children received all or any of the incorrect dose of medication. ‘Near miss’ was where the prescribed, prepared or dispensed medication was not administered to the child.

Main outcome measures Incidence, patient characteristics, setting, drug characteristics, outcome, harm and enabling or preventive factors.

Results In total, 50 10-fold errors were reported; 20 definite and 30 near miss cases. This yields a minimum annual incidence of 1 per 3797 admissions, or 4.6/100 000 children. Of these, 43 were overdoses and 7 underdoses. 33 incidents occurred in children <5 years of age. Overall, 37 different medications were involved with the majority, 31 cases, being administered enterally. Of these 31 enteral medication errors, all definite cases (10) had received liquid preparations. Temporary harm occurred in 5/20 (25%) definite cases with one requiring intensive care; all fully recovered.

Conclusions In this first ever population surveillance study in a high-resource healthcare system, 10-fold errors in children were rare, sometimes prevented and uncommonly caused harm. We recommend country-wide improvements be made to reduce iatrogenic harm. Understanding the enabling and preventive factors may help national improvement strategies to reduce these errors.

  • epidemiology
  • health services research
  • multidisciplinary team-care
  • therapeutics

https://doi.org/10.1136/archdischild-2020-319130

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    Footnotes

    • Twitter @YincentTse

    • Contributors YT and DT were the chief investigators, designed the protocol, collected the data, carried out the analysis and jointly wrote the paper.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval This study was submitted to, approved by and conducted via the Welsh Paediatric Surveillance Unit (WPSU). The WPSU is a national clinical surveillance body set up in 1994 to monitor the incidence and prevalence of a number of uncommon disorders of childhood. This project is not classified as research under the Research Governance Framework. Projects not classified as research are not managed as research within the NHS.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available on reasonable request. Data are confidentially stored by the Welsh Paediatric Surveillance Unit.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.