Inpatient paediatric medication errors - what can be learned from enquiries made to the National Poisons Information Service (Cardiff Unit)?

Introduction Medication errors are one of the more common types of medical error. Much of the research into medication errors and their prevention has been carried out in the adult population. Fewer data exist on medication errors in paediatrics. Children may be more affected than adults by adverse medication events because of their lower body weight, altered pharmacology and their dependency on adult carers. The National Patient Safety Agency (NPSA) strongly advocates an open reporting culture. Review of reported errors can generate learning points enabling improvements in patient safety. We wished to explore the incidence, nature and severity of reported adverse medication events occurring in paediatric hospital settings which resulted in telephone enquiries to the National Poisons Information Service (Cardiff Unit). Aim To identify and analyse in-hospital paediatric medication errors which resulted in advice being sought from the National Poisons Information Service (Cardiff Unit). Methods Information concerning enquiries to the National Poisons Information Service (NPIS) is recorded in a structured fashion using the United Kingdom Poisons Information Database (UKPID). This database was interrogated for enquiries to the Cardiff Unit over a 3½ year period between 2004 and 2007 to ascertain those medication errors occurring in hospital for children aged 16 years or less. Results There were 82 enquiries involving suspected childhood medication errors occurring in hospital during this period. These included 16 children aged