Nearly half the parents whose children were given the wrong treatment at the Royal Hospital for Sick Children in Glasgow were never told about the mistake, a new survey says.
The study, which reviewed five years of treatment errors at the hospital, showed fewer mistakes than expected. Overall, one mistake was made for every 662 children admitted to the hospital. They occurred most often on medical wards, and in 6 out of 10 cases nurses were to blame for the errors (Archives of Disease in Childhood 2000;83:492-7).
Most (96%) of the mistakes were classified as minor, although in 18 cases (9%) patients required intervention: in four cases children needed to be given another drug to counteract the effects of the first.
Mistakes were classified as serious in only two cases: in one case a child was given the wrong concentration of anticancer drug; in the second the infusion rate of a sedative was 100 times too high.
Most errors (56%) involved drugs given intravenously, commonly due to a pump error.
The authors of the study acknowledge that the level of failing to inform parents of the error (48%) was high compared with other studies. As parents were not present when errors occurred, and in most cases the children had not come to any harm, staff thought it was unnecessary to “cause undue stress” by telling them later, they said.
Throughout the study, policies on training and drug administration were constantly updated to try to reduce the rate of mistakes. A requirement to double check all drugs dispensed by the pharmacy, for example, reduced errors by over a third, from 9.8 to 6 a year.
In a commentary in the same issue of the Archives of Disease in Childhood (2000;83:496-7) Professor Terence Stephenson from Queen's Medical Centre in Nottingham said that all parents should be told about treatment errors. He estimated that at least 1675 avoidable treatment errors involving children occur in English hospitals every year, of which 85 are moderate to serious.
He suggests several ways in which doctors can help to avert such mistakes—for example, avoiding the use of decimal points and abbreviations in prescriptions and finding a quiet spot to check calculations rather than doing them in the middle of a ward round.