Errors, missed doses, overdose concerns and urgent escalation

A medicines error can occur at prescribing, supply, storage, administration, recording or monitoring. A near miss is an error that is detected before it reaches the child. Both are important because they reveal weaknesses in local arrangements. Homes should report and review incidents so lessons can be learned rather than hidden.

Urgent escalation is needed when a child may have had the wrong medicine, the wrong dose, a double dose, an overdose, a serious reaction or a time-critical omission. NHS guidance for children advises seeking prompt medical advice if a child may be reacting badly to a medicine. Immediate danger to life or rapid deterioration requires emergency action.

When urgent action may be needed

• Possible double dose: records are unclear or a second dose might have been given.
• Wrong child or wrong medicine: a mix-up has occurred or nearly occurred.
• Overdose concern: missing tablets, unsupervised access or deliberate ingestion is suspected.
• Serious reaction: breathing difficulty, collapse, severe rash or sudden deterioration after taking a medicine.
• Time-critical omission: missing the dose may itself create serious risk.

When medicine information does not line up, stop first and make it safe before you make it tidy.