Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error-reduction strategies.

Objectives To identify, review and evaluate the published literature on the incidence, type and causes of dispensing errors in community and hospital pharmacy. Method Electronic databases were searched from 1966 to February 2008. This was supplemented by hand-searching the bibliographies of retrieved articles. Analysis of the findings explored the research methods, operational definitions, incidence, type and causes of dispensing errors. Key findings Sixty papers were identified investigating dispensing errors in the UK, US, Australia, Spain and Brazil. In general, the incidence of dispensing errors varied depending on the study setting, dispensing system, research method and operational definitions. The most common dispensing errors identified by community and hospital pharmacies were dispensing the wrong drug, strength, form or quantity, or labelling medication with the incorrect directions. Factors subjectively reported as contributing to dispensing errors were look-alike, sound-alike drugs, low staffing and computer software. High workload, interruptions, distractions and inadequate lighting were objectively shown to increase the occurrence of dispensing errors. Conclusions Comparison of the reviewed studies was confounded by differences in study setting, research method and operational definitions for dispensing errors, error rate and classification of error types. The World Health Organization is currently developing global patient safety taxonomy. Such a standardized taxonomy for dispensing errors would facilitate consistent data collection and assist the development of error-reduction strategies.

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100 inpatient prescriptions (71 elective and 29 non-elective) and 35 discharge prescriptions were analysed.1. Weight was annotated for 84% of inpatient prescriptions and 94% of discharge prescriptions; height was not documented for any patient. Therefore data was analysed basing IBW on 50th centile of the UK growth charts.2. The following results are based on IBW: ▸ Six inpatients prescribed oral paracetamol were classified as overweight or obese; doses ranged from 17.4-30 mg/kg/dose. ▸ Four patients prescribed IV paracetamol were classified as overweight or obese; doses ranged from 20-23 mg/kg/dose. ▸ Four patients prescribed the combined route of PO/IV paracetamol were classified as overweight or obese; doses ranged from 18-24 mg/kg/dose. ▸ Six patients prescribed oral paracetamol on discharge were classified as overweight or obese; doses ranged from 13-33 mg/kg/dose.3. Paracetamol was prescribed as IV/PO in 32 inpatients.4. IV paracetamol was prescribed in 52 patients; 20 were not reviewed at 48 hrs for a switch to oral route. Of these, only 3 were appropriate prolonged IV prescriptions.Conclusion Audit findings showed inadequate compliance with local prescribing guidelines posing a risk of inappropriately high doses of paracetamol being prescribed to overweight and obese children. In addition, unnecessarily prolonged IV use was observed. Following feedback local guidelines were amended in 2015 to recommend that in obese children, dosing should reflect lean body mass and ideal weight for height. The maximum daily dose was also reduced to 75 mg/kg/day. Prescribers require education regarding this important issue.

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Objective To evaluate prescribing errors made during induction training and evaluate these for any common themes. Methods Four basic questions requiring five or six drugs to be prescribed were administered at the end of the Child Health Induction session for junior doctors. These focused on commonly used medications including analgesics and antibiotics. The doctors were given the BNF for Children (BNFC) and were allowed to use calculators. Answers were derived from the BNFC. We analysed errors by the following parameters: Route of administration, Dosage, Frequency and Dated and signed. Results 96 junior doctors participated between August 2007 and December 2009. 537 individual drug prescriptions were analysed revealing 114 errors (21.2%). Type of error Frequency Percentage of errors Dosage 58 50.8 Frequency 18 15.7 Dose and frequency 14 12.2 Not attempted 13 11.4 Dose mentioned as a range 9 7.8 Route of administration 1 0.9 Not dated and/or signed 1 0.9 Total 114 100 The 58 dosage errors included; underdose-47 (antibiotics), overdose-11 (antibiotics-5, analgesics-6). Conclusion Prescribing errors occur frequently in paediatric admissions with a small proportion causing harm.1 Suggestions to reduce medication errors in children include a recommendation that staff should have sufficient training and continuous education in the use of paediatric medications.2 The GMC emphasises the importance of safe prescribing by all doctors.3 Over recent years routine training and evaluation of junior doctors prescribing ability has been performed as part of Child Health induction training in Cardiff. A significant proportion of prescriptions had an error; around two thirds relating to incorrect dosage or frequency. Future teaching will try to target these mistakes. Mandatory prescription training and evaluation seems valuable.

There are several pharmacy and clinical pharmacology organizations in which pediatrics is one of many special interest groups and a few whose focus is entirely pediatric drug therapy. Recently the foundation for the establishment of an International Network of Paediatric Pharmacists has been laid. This paper describes that network.