Ten thousand safety alerts over medication given to children are being issued annually in the NHS, including serious errors in the calculation of drug doses and health workers forgetting to give patients their medicine, research shows.

The first report into health service safety incidents concerning children shows that 61,000 alerts were recorded between October 2007 and September 2008 in the care of patients under 18, with 18,200 involving babies aged under 1 month.

A quarter of the cases were the result of misuse of medication, including examples where patients received ten times too much of a drug owing to a dosing miscalculation. There were more than 2,800 alerts involving wrong or unclear dose or strength and children under the age of 4 were particularly affected.

The report, by the National Patient Safety Agency (NPSA), concludes that over the period there were 33 deaths of children and 39 deaths of newborn babies that had “indicators of avoidable factors”.

The findings echo concerns raised in recent years over the lack of treatments tailored for children, and how nurses are often left to carry out complex calculations to ensure that the right amount of a drug tested for adults is given to a child.

The report is the first to calculate the impact of safety alerts on children. It uses information sent in from health trusts to the NPSA’s Reporting and Learning System (RLS) and analysis of key research papers. Of the 900,000 alerts issued annually, 7 per cent were found to involve people under 18. Researchers found that children up to the age of 4 had the second-highest percentage of medication incidents of all age groups, after the over-75s. Most of the incidents reported to the NPSA resulted in no harm or low harm to the baby or child.

Jenny Mooney, head of child health at the NPSA, said that one concern was the very small number of alerts from the primary care sector — only 4 per cent of the 61,000 total — suggesting that the figure was a substantial underestimate.

Dr Mooney said that the review showed that errors could occur when calculating and preparing drug doses for children. “It comes down to the availability in terms of drugs. You would always try to get them in liquid form, but sometimes you may not be able to. You end up having to crush up tablets . . . and it is fraught with potential problems.”

Other examples included confusion over milligrams and micrograms. Among babies, errors relating to treatment or procedure was the most common incident type (3,294 alerts), followed by medication incidents (2,881). Among children, medication incidents were the most commonly reported incident type (7,029), followed by treatment or procedure (5,416) and accidents involving the patient (4,576).

Dr Mooney added that she hoped that reporting of alerts would continue to improve, because a high number of reports did not necessarily indicate that a trust was performing poorly, but that its surveillance was thorough. “It is about changing the culture of reporting,” she said.

The report, called Review of Patient Safety for Children and Young People, said that more than half of accidents involving children related to slips, trips and falls. The report noted that 2,000 children a week are admitted to hospital with accident-related injuries and added: “It can therefore be anticipated that children will also be at risk of accidents while in hospital, and appropriate safeguards should be in place to protect children from accidental injury while receiving healthcare.”

The NPSA is urging NHS organisations to examine a range of best-practice guidance to help to cut the number of incidents, and better training for staff and a review of local procedures for managing medicines.

Kevin Cleary, the NPSA’s medical director, said that the agency had highlighted a range of recommendations for best practice to help to improve care and reduce safety problems: “The majority of patient-safety incidents involving children were reported to have resulted in no harm or low harm. However, we are hoping this constructive feedback will support all trusts and clinicians in delivering even safer clinical care to all NHS patients in the future.”

Case Study: Gentamicin

Gentamicin, an antibiotic used to treat bacterial infections in the very young, was the subject of 400 safety alerts between April 2007 and March 2008.

It is administered intravenously for the treatment of neonatal sepsis, but has a narrow therapeutic range: slightly too little or too much can affect its toxicity and efficacy.

An analysis of Reporting and Learning System data for neonatal medication incidents involving gentamicin identified 400 incidents. Two thirds of these were related to problems with administration of the drug, 23 per to prescribing and 6 per cent to insufficient monitoring.

Gentamicin is the subject of a joint project between the National Patient Safety Agency and the Royal College of Paediatrics and Child Health relating to safe administration.

Best practice in neonatal care, being piloted, includes “no interruption” policies during prescribing, preparing, checking and administering; use of a 24-hour clock when prescribing; and administration of the dose to be given within one hour either side of the prescribed time.

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