Pharmacy Daily | Children at unique risk of dispensing errors

PHARMACEUTICAL Defence Limited (PDL) has issued an alert reminding pharmacists to carefully consider prescriptions and over-the-counter requests for children, after an annual review identified that kids were involved in 9% of all PDL incident reports.

The data raises concerns for PDL officers, who acknowledged that incidents involving children may be reported more frequently, as people are more likely to be concerned with an error if it involves a child, regardless of the outcome.

While most of those incidents stated that no consequence or harm occurred, around 25% referenced some form of complaint, whether to pharmacy management or owners, or to a regulatory agency.

Most incidents involving children happen when there is a mistake with dispensing medication, such as the wrong dosage or labelling.

For example, doctors are likely to prescribe medicine for a child in milligrams rather than millilitres, and when pharmacists input the data into the dispensing software using the milligram dose, the software sometimes converts that numeric value into millilitres, leading to an excessive dose when the liquid is a concentrated form of the medicine, according to PDL.

Other incident causes include lapses in compounding practice, which have led to errors in the strength of compounded medicine for children, and general dispensing errors, such as the wrong drug or strength selected.

PDL has also received reports of children taking medicine prescribed for adults, and is encouraging pharmacists to remind patients about safe storage, especially for potent sedating medicines.

Children are "uniquely at risk", PDL emphasised, due to "their distinct physiological characteristics, dependence on parents/caregivers for communication, and increased vulnerability to dosing deviations", and therefore require a tailored approach from pharmacists.