Tenfold Medication Errors in Children and Young People
Research type
Research Study
Full title
Tenfold or greater Medication Errors both under and over-doses in Hospitalised Children and Young People.
IRAS ID
369075
Contact name
Charlotte King
Contact email
Sponsor organisation
Alder Hey Children's Hospital
Duration of Study in the UK
3 years, 0 months, 1 days
Research summary
Medication errors are common (237 million per year in the UK). Children and young people are at three times more likely to be harmed due to medication errors compared to adults. The majority of paediatric errors in the United Kingdom (UK) involve prescribing or giving medicineS. Within paediatrics, medicines often require adapting depending on weight, age, or body surface area. Changes in formulations such as liquid or tablets and the use of off-label/unlicensed medication use adds to the potential areas of error. Issues involving medication errors involve all healthcare providers and patients and their families.
Amongst children, tenfold dose errors have the potential to cause harm and even death and is of great concern. Tenfold or greater errors both under- and over-doses can occur throughout the medicine process (ten-fold). A recent Healthcare Safety Investigation Branch (HSIB) report highlighted issues that can occur around weight based medication errors, leading to significant morbidity.
A previous Welsh Paediatric Surveillance Study about tenfold medication errors across hospitalized children in Wales identified 20 definite cases, where the medication was given, over two years (of which, 25% lead to harm). Despite the current safety systems, tenfold errors occurred at every stage of the medication process. The below table highlights how medication errors may occur before, during and after a medication error. However, the incidence of tenfold errors is uncertain on a larger scale, we know they occur but is unclear as to the scale that this happens across the UK.
This study aims to increase our knowledge of this issue, tenfold medication errors in children and young people. By understanding and recognising these errors, strategies could be developed to limit the errors on a national basis. By identifying information around these types of errors we will hope to improve patient safety and reduce the risk to patients and their families with medications. The project is in collaboration with the BPSU and Neonatal and Paediatric Pharmacy Group.
REC name
Yorkshire & The Humber - Sheffield Research Ethics Committee
REC reference
26/YH/0144
Date of REC Opinion
10 Jul 2026
REC opinion
Favourable Opinion