Lead investigator
Dr Charlotte King
Paediatric Registrar
Alder Hey Children’s Hospital
charlotte.king@alderhey.nhs.uk
Co-investigators
- Dr Daniel Hawcutt, Alder Hey Children’s Hospital
- Dr Yincent Tse, Great North Children's Hospital
- Dr Andy Fox, University Hospital Southampton
- Steve Tomlin, Great Ormond Street Hospital
- Delfi Warner, Parent Representative
- Helen Baldwin, Alder Hey Children’s Hospital
About the study
Medication errors are common (237 million per year in the UK). Children and young people are at three times more likely to be harmed due to medication errors compared to adults. The majority of paediatric errors in the United Kingdom (UK) involve prescribing or giving medicines. Within paediatrics, medicines often require adapting depending on weight, age, or body surface area. Changes in formulations such as liquid or tablets and the use of off-label/unlicensed medication use adds to the potential areas of error. Issues involving medication errors involve all healthcare providers and patients and their families.
Amongst children, tenfold dose errors have the potential to cause harm and even death and is of great concern. Tenfold or greater errors both under- and over-doses can occur throughout the medicine process.
This study aims to increase our knowledge of this issue, tenfold medication errors in children and young people. By understanding and recognising these errors, strategies could be developed to limit the errors on a national basis. By identifying information around these types of errors we will hope to improve patient safety and reduce the risk to patients and their families with medications. The project is in collaboration with the RCPCH/ Neonatal and Paediatric Pharmacy Group (NPPG) Joint Standing Committee on Medicines (Medicines Committee).
Reporting instructions
Please report all existing and new cases you have seen in the last month fulfilling this case definition of ROHHAD (in the UK and Republic of Ireland) not previously notified.
Case definition
Please report any child or young person from 0 to 15 years of age who received all or any part of a dose of medication that was prescribed and delivered in a hospital setting, that was:
ten times or more than the intended dose
or
- a tenth or less than the intended dose.
Inclusion Criteria:
- Aged 0-15 years old
- Received a tenfold (under or over-dosing) medication error in a hospital setting (includes emergency department, ward admission, day case unit, surgical wards, neonatal and paediatric intensive care environments)
- Reaches NCC MERP classification grade C to I
- Medication involved includes intravenous, inhaled, topical, rectal and oral formulations.
Exclusion Criteria:
- Aged 16 years and over
- Did not receive a tenfold (under or over-dosing) medication error
- Received a tenfold medication error outside of the hospital environment i.e. in their home environment
- Error due to access issue in patient or issue due to delivery of medication via machine
Duration
BPSU surveillance will be undertaken for 25 months, commencing with the November 2026 card.
Funding
Alder Hey Children’s Charity, Liverpool Health Partners - Joint Research Office
Approval
The study was approved by the Research Ethics Committee and the Health Research Advisory Group (England and Wales) (REC Reference 26/YH/0144; IRAS project ID 369075), the Public Benefit and Privacy Panel (Scotland) reference TBC, the Privacy Advisory Committee (Northern Ireland) and has been granted Section 251 HRA-CAG permission (CAG reference: 26/CAG/0070).