What’s New in the Patient Safety World


July 2009


NPSA Review of Patient Safety for Children and Young People


The National Patient Safety Agency in the UK has published its report “Review of patient safety for children and young people”. This summarizes learnings from data reported in the NPSA’s Reporting and Learning System (RLS). Of almost a million incidents now in that system, 2% relate to neonates and 5% to children. They acknowledge that reporting of incidents from primary care areas has been suboptimal so most of the incidents in the database come from hospitals.


The most commonly reported safety incident involving children or neonates related to “medication incidents”. In fact, the age group 0-4 had the second highest incidence of medication errors, surpassed only by the over 75 age group. Incorrect dose or strength was a big problem, including multiple examples of erroneous calculations and problems with decimal points (leading to 10-fold dosing errors). Note that a recent study in Austrailia also pointed out deficiencies in drug dose calculation skills, particularly of housestaff and less experienced physicians.


The report also highlights problems with recognition of severity of illness and continued problems with communication as issues of concern. Interestingly, the third most common type of incident was “slips, trips and falls”. Actually that should not be so surprising since in the age group of concern, slips trips and falls are very common amongst those healthy children who are not hospitalized. It does, however, emphasize the need to consider fall risk in our assessments of children as well as adults during hospitalization.





NPSA (UK). Review of patient safety for children and young people. 2009




Simpson CM, Keijzers GB, Lind JF. A survey of drug-dose calculation skills of Australian tertiary hospital doctors. Med J Aust 2009; 190 (3): 117-120















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