Table 1 Recent National Patient Safety Agency initiatives aimed at the safety of children
Alerts
    Alert 19. Promoting safer measurement andTo avoid oral medicines/feeds being given intravenously, all oral liquid medicines should now be administered via
    administration of liquid medicines via oral andan oral/enteral syringe. The sales of oral syringes in the NHS have increased dramatically. Manufacturers of tube
    other enteral routesfeeding equipment are in the process of changing the connections in nasogastric feeding systems and have indicated that they will be in compliance by April 2008.
    Alert 20. Safer use of injectable medicinesNHS trusts have until the end of March 2008 to complete a risk assessment of injectable medicines and introduce initiatives to better manage those risks. This will include implementing multidisciplinary standards and procedures for the preparation and administration of injectable medicines, training, better technical information in clinical areas, and greater use of ready-to-use and ready-to-administer injectable medicines. It is unlikely that all the risk reduction initiatives will be introduced before mid-2008.
    Alert 21. Minimising the risks ofNPSA initiative to prevent serious hyponatraemia in children. The recommended actions include removal of 0.18%
    hyponatraemiasaline with 4% dextrose from all but specialist areas. Comments to the NPSA indicate that NHS trusts have withdrawn the routine use of hypotonic infusion solution in general paediatric areas.
Rapid Response Reports*
    RRR1 (June 2007)Risk of confusion between cytarabine and liposomal cytarabine (Depocyte)
    RRR2 (September 2007)Risk of confusion between non-lipid and lipid formulations of injectable amphotericin
    RRR 4 (November 2007)Fire hazard with paraffin based skin products on dressings and clothing
  • *In June 2007 the NPSA started to issue Rapid Response Reports – some reports have addressed risks for both adults and children.

  • NHS, National Health Service; NPSA, National Patient Safety Agency; RRR, Rapid Response Report.