P26 A journey to improve the safety of iv paracetamol prescribing and administration in neonates and small children

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Since September 2014, BNFC has suggested an intravenous paracetamol (IV-P) dosing regimen for children under 10 kilograms which has on occasions been misinterpreted resulting in total daily dose >30 mg/kg being prescribed and administered.


Reported errors with IV-P include accidental overdose in children associated with the large vial size, 10-fold drug calculation errors, confusion between the dose volume in millilitres and milligrams and errors when setting up infusion pumps to administer a dose.1–3


Furthermore, in 2006 the NPSA raised an alert which created concern with the risk of inadvertent overdose of IV-P in children, citing over 200 incidents including two associated with severe harm.4


The aim was to decrease the rate of medication incidents involving IV-P prescribing and administration in neonates and small children.


In 2015 we introduced a number of measures to target prescribing and administration errors in the hospital. These included:


Datix reports of medication incidents involving IV-P were collated from January 2014 – June 2016. In the preceding 17 month period before the interventions the average IV-P reporting rate was 0.94 incidents per month. In the initial 9 month period following the introduction of the above measures, reported medication incidents involving IV-P were reduced to zero, however this effect started to diminish from month 10 onwards (March 2016). The average incident reporting rate for the 9 month post-intervention period was 0.38 incidents per month.


The measures introduced were initially effective in reducing the rate of medication errors involving IV-P however the efficacy diminished after a period of approximately 9 months. This period coincided with medical staff changeover however this may be an incidental finding.


Clear benefits to the safety of IV-P prescribing and administration have been demonstrated however strategies to provide sustainability of this approach through integration with regular nursing and medical education should be explored.

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