RCPCH/NPPG publish a new guideline on medicine safety

The Royal College of Paediatrics and Child Health and Neonatal and Paediatric Pharmacy Group Joint Standing Committee on Medicines (RCPCH-NPPG) have produced a new clinical practice guideline on medication safety, with recommendations on effective paediatric ward rounds.
Pharmacist prepares some medication

This clinical practice guideline has been developed in response to a national investigation into weight-based medication errors in children by the Healthcare Safety Investigation Branch (HSIB) in 2022. The report investigated the case of unintentional repeated tenfold overdose with dalteparin in a four-year-old child who suffered neurological harm.

We encourage all practitioners, providers of care and national organisations committed to improving safety of medicines in children to review and implement the recommendations in the clinical practice guideline.

Chair of RCPCH Medicines Committee, Dr Dan Hawcutt said:

Paediatricians have been aware for a long time that there are specific risks related to medicines in children and young people, above those for the rest of the population. This is partly due to the need for bespoke dosing, the massive variation in our population from premature infants to adult sized teenagers, the use of off-label and unlicensed medicines, liquid formulations of various strengths, and more.

In particular, tenfold weight-based dosing put this in sharp focus. The clinical practice guideline is a first step towards tackling this, providing agreed standards for how medicines should be considered on ward rounds for paediatric inpatients, as well as after discharge. In particular, we are very pleased with the expert input from the Neonatal and Paediatric Pharmacy Group (NPPG) as part of the joint medicines committee, whose help was invaluable.

Access the medication safety clinical practice guideline