Mental HealthTake Steps To Learn From Child Medication Errors, MDU Urges GPS, UK
The Medical Defence Union (MDU) is reminding its GP members about the steps they can take to avoid medication errors when treating children and the importance of learning from errors. The advice follows the publication of the National Patient Safety Agency"s (NPSA) first review of patient safety incidents involving the under 18s reported under the national reporting and learning system (RLS).
The NPSA report found that around 60,000 children suffer from medical errors each year and of these medication incidents were the most commonly reported problem.*The vast majority of reports were from hospital staff and only four per cent of cases were from primary care. The areas where medical errors were most likely in primary care were in vaccination and failed or wrong diagnosis of illness.**
Dr Karen Roberts, clinical risk manager at the MDU, said:
"Medication errors and delayed or wrong diagnosis are the two commonest reasons for GP claims reported to the MDU, so our experience mirrors that of the primary care incidents reported to the NPSA. Treating children can be fraught with difficulty for GPs as children are not "mini-adults". GPs will need to ensure that the correct drug formulation is prescribed and crucially in the correct dose. This will sometimes require specific calcualtion according to the infant"s weight. In addition, while many vaccines are administered safely and appropriately in primary care, GPs still frequently seek advice on the MDU"s medico-legal advice line following a vaccine administration error. It is vital that drugs are carefully checked before administration and doses are accurately calculated before prescribing. The Children"s BNF is an excellent re.
"With delayed or missed diagnoses, difficulties arise because young children cannot communicate their symptoms and patterns of presentation of illnesses may be different in children, particularly younger children, when compared to adults. Parents are usually very good judges of when their child is ill and can provide vital information about symptoms.
"If things go wrong, GPs should apologise to patients or in the case of young children, to their carers and provide them with a clear explanation of what happened. It is just as important to ensure any lessons are learnt from incidents and we encourage GP members to have an adverse incident reporting system in place in their practice and to report incidents to the NPSA under the RLS. The new complaints procedure also emphasises the need to review all complaints and analyse them to lessen the possibility of patients being harmed."
An earlier MDU study into paediatric medication in general practice*** found that twenty per cent of cases alleging medication errors over a seven year period involved under 15s. Common reasons for allegations being made against GPs were adverse drug reactions, wrong dose and parental consent not being obtained. A more recent analysis of 78 calls classified as adverse incidents on the MDU"s medico-legal advice line, over a one month period, revealed that around a third (25) related to a prescribing problem - of these 17 occurred in general practice. Five of these were vaccine errors.
Vaccines were also involved in 60 per cent of cases in the MDU"s earlier prescribing analysis. The MDU issued the following risk management advice to help primary care staff avoid vaccine errors:
- Ensure you note in the medical records if children with capacity or those with parental responsibility have withheld authority for a specific vaccine.
- Check the records before administration of a vaccine, and check with the parent, rather than rely only on the standardised initiation letter. This can avoid an infant being given an injection twice in error.
- Check the status of the accompanying adult to ensure that he or she has parental responsibility and can authorise the treatment.
References
- Review of patient safety for children and young people, NPSA, 17 June 2009, http://www.npsa.nhs.uk.
- Children worst affected by hospital drug errors, Guardian, 18 June 2009
- Paediatric medication incidents, MDU, October 2004, http://www.the-mdu.com.
MDU