In consultation with members, the College identified priority areas for improvement that have good evidence of viable improvement strategies, and where the influence of the College could meaningfully strengthen outcomes for children and young people.
Three areas stood out: systems for improving management of the deteriorating child (see PEWS); managing current and future safety through situational awareness (see S.A.F.E); and paediatric medication safety. With evidence that children are three times more likely to be harmed by medication errors than adults (Kaushal et al., 2001), paediatric medication safety has since been recognised as one of the five WHO world patient safety goals (2025).
Introducing our new position statement on EPMA systems
Our new position statement from the joint RCPCH and NPPG Medicines Committee focuses on a specific example within this third area: how electronic prescribing and medicine administration (EPMA systems) can be optimised for children and young people.
The statement explains how regulatory, commissioning and human factors have led to highly varied EPMA systems across the NHS that are not meeting the specific needs of medicine management in paediatrics, particularly in relation to weight-based dosing.
The 2022 Healthcare Safety Investigation Branch (HSSIB) report on weight-based medication errors in children highlighted the need for appropriate regulation and standards to ensure patient safety when commissioning and maintaining EPMAs, supported by consistent messaging from the Medicines and Healthcare products Regulatory Agency (MHRA) and NHS England. However, despite these clear signals, the statement concludes that “nothing has materially changed”.
Our position statement articulates practical steps that can be taken by Trusts and Health Boards who are commissioning and managing EPMAs. These are centred around appropriate linking to the British National Formulary for Children, or BNFC (see recommendations 1-3).
Our statement recognises the need for appropriate infrastructure to share and learn how the range of EPMA systems across the UK are commissioned, designed and used in practice. At present, we are not aware of any such mechanism being in place. However, we note that cases and variation could be collated and shared through RCPCH if there is appropriate collaboration from NHS providers and the Department of Health and Social Care (see recommendation 4).
Finally, serious consideration should be given to how standards and support tools could be developed to ensure improvements and reduced variation across the UK (recommendation 5).
The five recommendations
- All EPMA systems should be designed and usable in a way that ensures that:
- paediatric prescribing be based on the latest version of BNFC, supplemented where necessary by organisation-specific guidance
- paediatric prescribing incorporate drug calculations based on patient anthropometry
- medicines information be presented in the patient context
- condition-specific dosing be supported
- clinical decision support in paediatrics be provided by regulated medical devices.
- BNFC serves as the definitive national resource for safe and effective paediatric prescribing, providing a foundation for standardised dose based on age, weight and body surface area (BSA). As such, BNFC-based dosing should be the basis for EPMA systems across the UK to calculate paediatric dosages and set safety dose limits - all of which should ideally account for child anthropometry and the medical condition being treated.
- Local guidelines may be needed to supplement BNFC. But these additions should be limited to genuinely necessary cases and be clearly marked to distinguish them from national standards, preserving governance clarity and consistency.
- Consideration should be given to set up a process for providers to share variation in practice with RCPCH so that other providers can learn and improve.
- Consideration should be given by key stakeholders, including RCPCH, to develop paediatric specific standards with associated measures and improvement support tools.
Going forward
This is a ‘wicked’ problem (it's complex and multifaceted), and the Medicines Committee will work with the wider NHS to develop appropriate regulation and standards.
We hope that in the next few years we can develop processes to implement these five recommendations, and so reduce medication harm for children and young people.
What can you do?
Highlight the position statement in your governance meetings and with pharmacy and digital leads in your NHS Trust. If your paediatric unit has yet to purchase your EPMA system, help ensure the statement's recommendations are part of your tender process.
Together we can make a difference.
For more information on safety in paediatrics and child health, please visit our Patient Safety Portal. And look out for our Safety eBulletin, which are emailed every two months to members opted in get College updates (you can check your contact preferences on your online account).