Safe Prescribing for Children

1
Safe Prescribing for Children

• Case Studies

2
Paediatric Case Study

• Incident report
• Zulekha was prescribed carbamazepine as 280 mg
  9 ml. On checking I calculated 280 mg to be 14
  ml which was what was written on the patients
  own supply. Unfortunately I took this as
  correct, crossed off the 9 ml and gave 14ml. Had
  I checked the dose, I would have realised it was
  too high. When checked against the last clinic
  letter, the dose was 180 mg. Evening dose to be
  omitted, own supply to be returned. Mum informed
  of error

3
Root Cause Analysis

• What happened?
• There were two prescription errors (pharmacy and
  doctor) and one administration error (staff
  nurse)
• Carbamazepine in BNF for Children Tegretol
  suspension contains carbamazepine 100mg/5 ml.
• Doctor prescribed carbamazepine 280 mg (9 ml)
  b.d. 9ml180 mg ( if 100 mg/5ml)
• Patients bottle ( from Community Pharmacy)
  labelled 300 ml Carbamazepine liquid 100mg/ml,
  give 14 ml twice daily 14 ml1400 mg
• Nurse crossed out the 9 ml and gave 14 ml as
  stated on the patients bottle. 14 ml280 mg

4
Root Cause Analysis (2)

• How did it happen?
• Wrong concentration and instructions from
  Community Pharmacy
• Wrong (different) concentration prescribed by
  doctor
• Wrong dose given by staff nurse

5
Root Cause Analysis (3)

• Why did it happen?
• Community Pharmacy did not follow BNF
  recommendations.
• Prescribing doctor did not check dose/
  concentration in the BNF for children
• Administering nurse did not check
  dose/concentration in BNF for children.

6
Root Cause Analysis (4)

• Mother I usually give 9 ml (180 mg) twice daily
  as I was told in clinic (last clinic letter says
  180 mg/ 9 ml. twice daily). I have spoken to my
  GP and asked him to change the label on the
  bottle but he said that as long as I know what
  to give, then it doesnt matter.

7
Lessons Learnt

• Use only approved concentration of carbamazepine
  oral suspension according to BNF for children
• Check all prescriptions against BNF for children
• Prescribe in mg not in ml.
• Patients case notes or at least latest clinic
  letter should be available at the time of
  admission
• Listen to the parents!

8
Paediatric Case Study 2

• Child (d.o.b. 15/04/99, wt 16 kgs) admitted to
  AE in Status Epilepticus was given 15 mg of
  rectal diazepam.
• 3 hours later on the ward her Glasgow Coma Scale
  was 4.

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Root Cause Analysis

• What happened?
• -Child given inappropriately large dose of
  rectal diazepam
• How did it happen?
• -1. Incorrect weight estimation 24 kg on
  Breslow scale, real wt (age4)x2 16 kg.
• -2. AE Status Epilepticus Protocol for
  children indicates dose of rectal diazepam is 0.5
  mg/kg
• Why did it happen?
• -Because there is no maximum dose of rectal
  diazepam for age in the Status Epilepticus
  Protocol

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Lessons Learnt

• APLS (Advanced Paediatric Life Support) formula
  should be used for estimating weight in
  emergencies
• Maximum dose of rectal diazepam for age group
  should be available in the protocol
• Status Epilepticus Protocol modified