In a one year period, the researchers found that over 60,000 children were exposed to clinical mistakes, the majority of which were cases where the patient was administrated with an incorrect dose of medication or where no medication was provided at all. Medication errors are particularly worrying as they can have very grave effects for the patient. The research by the NPSA found that 33 children and 39 babies under one year died following provision of an incorrect dose of medication.
The NPSA have urged drug companies to begin to manufacture medications in child doses as well as adult doses in the hope that fewer administrational errors can be made. When dealing with such a small body mass, a slight increase in medication can cause disastrous consequences. It is therefore extremely important that prescribed doses are checked and checked again.
In one very sad case in January this year, a Sheffield inquest heard how a 4-month old baby girl died after being prescribed over 10 times the correct amount. The receptionist of the baby’s GP surgery typed out a prescription for 5mls of the medication to be taken twice a day instead of 0.5mls. An automatic warning popped up on the computer screen but was overridden by the receptionist. The prescription was then signed by the GP before being given to the child’s parents but the mistake was not noticed.
There was yet another chance for the error to be picked up on. The medication was dispensed by a pharmacist who had overheard his technician question the dose. The technician had phoned the surgery but it was not checked with a doctor before the prescription was given to the baby’s parents.
This series of errors meant that the mother of the child was unwittingly administrating her baby with an overdose of medication. The child fell seriously ill and was soon admitted to the Children’s Hospital in Sheffield where a further two doses of the incorrect amount were delivered before the mistake was registered. The pathologist at the inquest confirmed that the overdose may have caused the baby’s death and at least contributed to it.
It is shocking that a simple administrational error could have such horrendous consequences but it is also extremely worrying that the mistake was not picked up on by any of the medical practitioners involved despite numerous opportunities. This tragedy was one that would likely have been avoided had those involved taken a little more time and care. (Source)