Linda Haines

Interventions to reduce dosing errors in children: a systematic review of the literature.

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions foundwere computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that ‘smart’ intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.

Interventions to Reduce Dosing Errors in Children

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions foundwere computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that ‘smart’ intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.

Cost-effectiveness of digital photographic screening for retinopathy of prematurity in the United Kingdom

OBJECTIVES To compare the cost-effectiveness of alternative methods of screening for retinopathy of prematurity (ROP) in the United Kingdom, including the existing method of indirect ophthalmoscopy by ophthalmologists and digital photographic screening by nurses. METHODS A decision tree model was used to compare five screening modalities for the UK population of preterm babies, using a health service perspective. Data were taken from published sources, observation at a neonatal intensive care unit (NICU), and expert judgment. RESULTS We estimated that use of standard digital cameras by nurses in NICUs would cost more than current methods (pound 371 compared with pound 321 per baby screened). However, a specialist nurse visiting units with a portable camera would be cheaper (pound 172 per baby). These estimates rely on nurses capturing and interpreting the images, with suitable training and supervision. Alternatively, nurses could capture the images then transmit them to a central unit for interpretation by ophthalmologists, although we estimate that this would be rather more expensive (pound 390 and pound 201, respectively, for NICU and visiting nurses). Sensitivity analysis was used to examine the robustness of estimates. CONCLUSIONS It is likely that there is an opportunity to improve the efficiency of the ROP screening program. We estimate that screening by specialist nurses trained in image capture and interpretation using portable digital cameras is a cost-effective alternative to the current program of direct visualization by ophthalmologists. This option would require the development of a suitable portable machine. Direct comparative research is strongly needed to establish the accuracy of the various screening options.

Educational interventions to reduce prescribing errors.

Objective: Little is known about teaching paediatricians to prescribe or about assessing their competency. This study aimed to identify educational interventions to reduce dose calculation errors. Design: Literature review, a questionnaire survey of paediatric healthcare professionals, observation and interviews were performed. Results: Literature review identified one paper describing an in-service test for medical trainees. 319/559 questionnaires were returned (57%). 34 mentioned educational interventions, 15 centres provided further information on teaching and assessment methods and 13 provided presentations, usually at doctors’ induction. Many interventions had a similar format, including describing differences from adult prescribing, common errors and how to calculate doses. Paediatric clinical pharmacists play a significant role in delivering training and competency assessment. Conclusion: Teaching of paediatric prescribing takes place mostly in the format of lectures during doctors’ induction. Few centres assess competency and no validated tool exists. There has been little evaluation of the impact of teaching on competency to prescribe.

Health-related quality of life of children with vision impairment or blindness

The aims of the study were to describe the functional ability, health status, and health‐related quality of life (HRQL) of young children with a vision impairment or blindness (VI/BL) and to examine the effect of different types of ophthalmic condition and the presence of other impairments or systemic disorders. A cross‐sectional community survey of children aged 3 to 8 years with VI/BL was conducted in four areas of England using the Health Utilities Index Mark 3 system. Seventy‐nine children (47 males, 32 females; mean age 6y 2mo [SD 1y 6mo]) met the selection criteria: 43% had a visual pathway condition, 38% a condition of the eye, and 19% nystagmus alone; and 61% had additional impairments/disorders. Eighty per cent had functional limitations on at least two of the following attributes: vision, hearing, speech, cognition, ambulation, dexterity, emotion, and pain. Forty‐four per cent had functional limitations on four or more attributes. Children with nystagmus alone had significantly higher mean HRQL utility scores (0.80 [SD 0.26]) than children with a condition of the eye (0.45 [SD 0.33]), who, in turn, had higher scores than children with a visual pathway condition (0.05 [SD 0.33], p= 0.002). Children with an isolated VI/BL had significantly higher mean scores (0.73 [SD 0.21]) than those with additional impairments/disorders (0.09 [SD 0.34], p < 0.001). These findings underline the need for a broad assessment of each child with VI/BL and a multidisciplinary approach to care.

Management and 1 year outcome for UK children with type 2 diabetes

Objective: To report the 1-year outcome for children newly diagnosed as having type 2 diabetes in the UK. Design: Follow-up study of a UK national cohort. Subjects: All children under the age of 17 years diagnosed as having type 2 diabetes from 1 October 2004 to 31 October 2005 (inclusive). Results: Follow-up data were available for 73 of the 76 cases. The mean age at follow-up was 14.5 years, with mean duration of diabetes 1 year. The revised incidence of type 2 diabetes in the UK in children under 17 years is 0.6/100 000/year. The mean body mass index (BMI) SDS at diagnosis was 2.89, and mean change at 1 year was −0.11 (range −1.53 to +1.37). At 1 year, only 58% achieved the American Diabetes Association/European Association for the Study of Diabetes recommended treatment target (glycated haemoglobin ⩽7.0%). There was no relation between improvement in BMI and improvement in glycated haemoglobin. There was wide variation in choice of treatments and regimens. Hypertension is a common comorbidity (34%), whereas early nephropathy appears to be rare (4%). Evidence of polycystic ovarian disease was common in girls (26%). 22% of children had not been screened for nephropathy or retinopathy during the first year after diagnosis. Conclusions: The 3.8% mean reduction in BMI SDS in the first year after diagnosis indicates that many children find it hard to make the necessary lifestyle changes needed to positively affect metabolic health. Physicians are using a wide variety of treatment regimens, which are relatively effective in achieving glycaemic targets, but systematic screening for complications is incomplete. There is an urgent need to develop an evidence base for effective treatment and management protocols to reduce the risks of long-term microvascular and macrovascular complications.

Complaints in child protection

The current difficulties facing paediatricians working in child protection have already been well documented.1–3 Studies have shown that as well as causing significant stress and psychological morbidity,4 complaints against UK paediatricians in relation to a child protection issue are becoming increasingly common.5 A survey of members of the Royal College of Paediatrics and Child Health (RCPCH) found that 13.8% of over 4500 respondents had been subject to a total of 786 complaints about child protection and that the number of complaints per year had increased from less than 20 in 1995 to over 100 in 2003.6 Although worrying, the finding that the number of child protection complaints rose fivefold in 4 years needs to be set in context. Over this same period there were still almost twice as many paediatricians with a non-child protection complaint against them, and information from the Medical Defence Union shows that complaints to the General Medical Council increased almost 15-fold between 1990 and 2003, an annual rise of 33%.7 If we are now more likely as a society to complain about any aspect of our medical care than we were a decade ago, why are child protection complaints of particular importance? The answer we believe is threefold. Firstly, the rising level of complaints is clearly making the paediatricians that society relies upon to protect vulnerable children feel demoralised and disengaged. The evidence is clear: 29% of paediatricians who have experienced a complaint are reluctant to take a future lead role in child protection,7 there are continuing recruitment difficulties in community paediatrics,8 9 and paediatric trainees are reluctant to consider a job with specified child protection responsibilities.10 However, the impact of complaints is not just felt by those who “specialise” in child protection. Protecting children is …

Systematic review of interventions to reduce dosing errors in children

Children are a particularly challenging group of patients when trying to ensure the safe use of medicines. The increased need for calculations, dilutions and manipulations of paediatric medicines, together with a need to dose on an individual patient basis using age, gestational age, weight and surface area, means that they are more prone to medication errors at each stage of the medicines management process. It is already known that dose calculation errors are the most common type of medication error in neonatal and paediatric patients. Interventions to reduce the risk of dose calculation errors are therefore urgently needed. A systematic literature review was conducted to identify published articles reporting interventions; 28 studies were found to be relevant. The main interventions foundwere computerised physician order entry (CPOE) and computer-aided prescribing. Most CPOE and computer-aided prescribing studies showed some degree of reduction in medication errors, with some claiming no errors occurring after implementation of the intervention. However, one study showed a significant increase in mortality after the implementation of CPOE. Further research is needed to investigate outcomes such as mortality and economics. Unit dose dispensing systems and educational/risk management programmes were also shown to reduce medication errors in children. Although it is suggested that ‘smart’ intravenous pumps can potentially reduce infusion errors in children, there is insufficient information to draw a conclusion because of a lack of research. Most interventions identified were US based, and since medicine management processes are currently different in different countries, there is a need to interpret the information carefully when considering implementing interventions elsewhere.