Theme | Error mechanism | Ref | Supporting quotation(s) |
Individualised dosing and calculations | Wide variation in size within the paediatric age range | 1PP1 2PP1 | [With paracetamol] the age band [dosing] has taken a lot of thinking out of it… there's very few months go by that I don't come across an age-banded dose of paracetamol that is essentially a toxic dose… It's 80, 85, 90 milligrams per kilogram per day. It doesn't account for the nutritionally depleted, very small-for-age child. On the other side of immaturity, I've seen instances where the bigger kid has got bigger doses than the maximum dose or the adult dose. |
Need for frequent changes to doses or dosing schedules | 3PP1 | Co-amoxiclav has come up in drug errors, and that has been prescribed every eight hours for a child within the first three months of life, whereas it [should be] every 12 hours. | |
Inadequate mathematical skills | 4PT2 | I like someone else to check it and say ‘yes, that is right’, and I like them to know where my calculations are coming from, but I find that some [team] members might need more help with calculations. | |
Calculation errors when distracted | 5PT1 | I prescribed an antibiotic on a busy ward round, I made a mistake in my calculation—it was an easy calculation, 10 kilo child, four milligrams per kilogram—I wrote the dose and prescribed 100 mg. It was a mistake, and I was just busy. The nurses mustn't have checked the dose—they gave the dose and then said to me after ‘gosh, that child has got quite a big dose, they gave them much more than I gave the child across the bay’ and I was like ‘oh, what happened?’ and then I knew straight away… I mean, I can do four times 10, I did A Level Maths, so distractions happen. | |
Problems with weights and weighing | 6PT2 | There are errors when you can't actually get a weight. I've had patients, because of certain problems, arthrogryposis comes to mind, (that weren’t) weighed and then received ibuprofen, more than what they should for their weight, and had kidney problems because of it… weights can be difficult and time consuming for the nursing staff. | |
Off-licence drug use | ‘Special’ formulations | 7PP1 | Off-licence medications are things that (aren’t) available with the UK licence… a specialist manufacturer somewhere will start producing a medication, or it'll be licensed in Europe or something like that, and we'll import that. Some of those products need translated so they don't have a UK label on them. |
Multiple, inconsistent resources | 8PT2 | A lot of centres, neonatal units, will have different prescribing manuals, so whereas you’re used to [using] a certain medication in such a way, you'll go to a manual, it'll say do it a different way. | |
Medication formulations | Formulations intended for adults | 9PP1 | They are liquid medications targeted at adult doses, so you can potentially give quite a lot more to a child than you intend to [without administering an] outrageous amount of liquid. If you're going to overdose an adult, you're going to have to give them 25 to 30mls, whereas with a small baby using that preparation you could do a lot of damage with 3 to 4 mils. |
Problems with liquid formulations | 10PN1 | That conversion from milligrams to mils will also be where errors occur. | |
Communication with children | Difficulties in accurate medicines reconciliation | 14PT1 | They make mistakes like telling you the wrong amount of mils, or they’re converting it to milligrams themselves—I was told 10 times the dose of a medication the other day, because the parents said it was 250 when it was actually 25—I think they must have tried to convert it themselves. |
Inadequate communication of prescribing decisions to parents | 15PC1 | I discover they only gave it for three days, and found that they couldn't [administer] it because they didn't know how to do it properly, and it's a very bitter medicine, and then they just gave up, and then this child's had two weeks with no treatment and then they're back to me and they are no better, and I have learnt through that. | |
Experience of working with children | Trying to remember doses rather than look them up | 11PT1 | Adults were set doses and if it was ‘came in with a chest infection from A&E’, oh you're going to prescribe them whatever the dose was; you would have known [without looking it up], and you probably just would have looked up their renal function, I wouldn't have looked up everything. |
Not recognising differences in prescribing for children | 12PT1 | I've had both [situations]—being in a District General [Hospital] with ENT surgery, either asking for your help, or fixing a prescription [on their behalf], and again with [intravenous] fluids, both asking for your help and fixing their prescriptions because they just didn't know. | |
Prescribers not checking, despite unfamiliarity | 13PN2 | It’s about a degree of self-confidence, in the sense that if you are checking and doing your independent calculations and everything else, then you have to be able to say ‘look, I don't understand this’ and not go with your colleague. So often we see [team members]… not even double checking or anything, just going ahead. |