Medication blunders have seen ill children given 10 times the dosage of drugs they were supposed to have, a new study has revealed.
Paediatric units across Wales were asked to report details about times they made "substantial mistakes" in the dosage given to patients under the age of 16.
This only included incidents where children had been given an overdose of 10 times or more what was recommended. It also included cases where children had been given significant underdoses.
According to the findings, six hospitals in Wales reported a total of 25 “tenfold or greater medication errors” between 2017 and 2018.
Medications that reached young patients included morphine, the antibiotic nitrofurantoin, epilepsy drug levacetirazam and sleep medication lorazepam.
In two cases, the errors resulted in children needing "initial or prolonged hospitalisation" - although the effects of the error were only said to have caused "temporary harm".
Seven other cases also saw the wrong amount of drugs administered to children, which resulted in them being monitored.
However, the other 15 errors were spotted before the medication was given.
Most of the errors were made during the initial prescribing process, followed by the administration stage and then dispensing.
Some 60% of reported overdosing or underdosing involved drugs given externally, while 40% were administered intravenously (directly into a vein).
According to the report, most of the mishaps happened at the Noah’s Ark Children’s Hospital for Wales in Cardiff.
David Tuthill, consultant paediatrician at the Noah’s Ark Children’s Hospital for Wales and author of the report, said several “human errors” were to blame
These included calculation mistakes, decimal places not being clear on prescriptions and confusion between mg and mg/kg.
“While this is very infrequent and involves a small number of patients, we are trying to get it down to zero,” he said.
“The aim [of the report] is to make things safer for children as this is happening across Wales."
Dr Tuthill added that most of those affected were children under the age of four who were more likely to be given liquid forms of medication - a more difficult form of drug in which to provide an accurate dosage.
He added that many of the errors were likely to have occurred in high-pressure situations in acute care when medication needed to be given quickly.
Of the 25 incidents, 22 were overdoses and three were underdoses.
"You cannot be an expert in all dosages," Dr Tuthill added.
"There are around 800 pages of medications for children alone.
"We get it right most of the time already, but human errors are inevitable."
Dr Tuthill said one of the best ways of reducing errors is to create an all-Wales standardised electronic medication support system.
He has also called for a standardised strength of liquid medicines for children.
However, he said the report did not look at whether the mistakes were likely to have been caused by staffing issues.
