Paediatric therapeutic errors reported to the UK National Poisons Information Service, occurring in the home

Objective: A retrospective review of enquiries to the UK National Poisons Information Service (NPIS) relating to therapeutic errors in children under 19 years of age. Methods: Data between January and December 2008 were reviewed; exposures occurring in the home were examined to establish type of agent involved, reason for the error and route and type of exposure. Results: During the study period, 23,387 enquiries relating to this age group were received by the NPIS, 1998 enquiries (8.5%) were due to therapeutic error. Of these, 21% were in children under 1 year, 12% in 1 year olds, 9% in 2 year olds, 6% in 3 year olds and 5% in 4 year olds, the older year groups remained between 3 and 4%. A total of 1759 (88%) exposures took place in the home. Of these, 93% involved ingestion with the remaining 7% being due to inhalation, injection, skin or eye contact. Fifty-four percent of exposures in the home were considered acute, in 20% the patient had taken an excess of their own medication, 18% involved a staggered exposure and 6% a sub-acute exposure. The class of drug most commonly associated with therapeutic errors in this group was analgesics (35%); respiratory medication 16%, CNS depressants 13%, antibiotics 11%, cardiovascular drugs 7% and gastrointestinal medication 4% were also implicated. Of the 606 enquiries relating to analgesic exposure in the home, 321 (53%) were deemed to be due to parental error, 151 (25%) to patient error and 9 (1.5%) were due to error by a healthcare professional. An incorrect analgesic drug was administered in 80 enquiries and of the 400 cases where an incorrect dose was given, 151 patients received double their prescribed dose, 138 received less than double and 111 received more than double - commonly 10 times the recommended dose. 15% (88) of analgesic exposures were regarded as potentially serious ingestions resulting in hospitalisation and/or medical treatment. Conclusion: The majority of therapeutic errors in children occur in the home, often as a result of parents giving extra doses. Help, perhaps in the form of a simple dosing chart, may significantly reduce these exposures.