Kids at Danger of Medicine Errors Below New Digital Programs, Security Watchdog Warns

Kids are liable to critical remedy errors from digital prescribing and medicines administration (ePMA) programs, regardless of the assumption that they’re safer than conventional prescribing practices, a healthcare security watchdog has warned.

Research present that prescribing errors are probably the most frequent sort of remedy error in paediatric inpatient settings, doubtlessly inflicting vital hurt or dying.

Prescribing for youngsters is advanced as particular person calculations are wanted for every youngster, taking weight, age, gestation and physique floor space into consideration. Whereas ePMA programs are actually regularly utilized in youngsters’s providers and are thought of a simpler solution to scale back remedy errors, they could trigger new technology-related errors, in keeping with a brand new nationwide investigation report from the Healthcare Security Investigation Department (HSIB).

Reference Case

The HSIB launched its investigation into the dangers concerned when prescribing, meting out and administering drugs to youngsters in January 2021, following the case of a kid who obtained 10 occasions the supposed dose of a blood thinning remedy.

The anticoagulant was prescribed by a junior physician utilizing an ePMA system, which had been carried out on the youngsters’s ward 10 months earlier than the incident.

Errors within the prescription, meting out and administration processes meant that the kid obtained 10 occasions the supposed dose on 5 separate events over three days.

A subsequent CT scan confirmed that the kid had a brand new right-sided bleed within the mind and he or she was admitted to the paediatric intensive care unit. Following 3 months in hospital, the kid was discharged dwelling with an ongoing care plan.


As a part of its wider investigation, the HSIB recognized numerous threat elements for potential ePMA errors, together with that there’s restricted nationwide steering and standardisation on the administration of ward rounds in paediatrics (as is out there for grownup care), there’s variability in hospital medical pharmacy provision, and there aren’t any requirements for what safety-critical performance must be accessible in ePMA programs utilized in paediatrics (for instance, the usage of weight-based dose bands, the place individually calculated doses are rounded to a set of predefined doses).


As a part of its investigation the HSIB made 5 security suggestions to enhance affected person security within the NHS.

  1. That the Royal School of Paediatrics and Little one Well being (RCPCH) identifies the very best follow ideas for efficient paediatric ward rounds in relation to medicines, and disseminates them to its members

  2. That NHS Digital and NHSX promote the organisational necessities for digital medical security, together with organisations’ tasks by way of security circumstances and medical security officers, to embody system performance and processes

  3. That the Care High quality Fee (CQC) opinions whether or not a supplier’s assurance of its compliance with the Medical Danger Administration commonplace particular to digital prescribing and medicines administration programs in healthcare, can kind a part of the CQC’s growing regulatory mannequin

  4. That the Nationwide Institute for Well being Analysis assesses the precedence, feasibility and influence of future analysis on processes for second checking remedy, and considers probably the most acceptable approach of increase the proof base on this subject

  5. That the Medicines and Healthcare merchandise Regulatory Company (MHRA) works with the producers of ePMA programs to supply steering on their obligations underneath the Medical Gadgets Rules 2002 (as amended)

Talking to Medscape UK, an RCPCH spokesperson stated: “We famous the report from HSIB on weight-based remedy errors in youngsters. This is a crucial situation and we welcome the publication of the report. There may be one advice for RCPCH so we’ll now take ahead dialogue to think about this.”

Big Prices

Medicine errors are a number one reason for damage and avoidable hurt in well being care programs globally, in keeping with the World Well being Group, with the price related to remedy errors estimated at $42 billion USD yearly.

As beforehand reported, greater than 237 million remedy errors are made all alongside the care course of yearly in England alone. These errors are estimated to value the NHS a minimum of £98 million and contribute to the lack of greater than 1700 lives yearly, in keeping with the research revealed in  BMJ High quality & Security .