Medication errors in a paediatric teaching hospital in the UK: five years operational experience
In the past 10 years, medication errors have come to be recognised as an important cause of iatrogenic disease in hospital patients. To determine the incidence and type of medication errors in a large UK paediatric hospital over a five year period, and to ascertain whether any error prevention programmes had influenced error occurrence. Retrospective review of medication errors documented in standard reporting forms completed prospectively from April 1994 to August 1999. Main outcome measure was incidence of error reporting, including pre- and post-interventions. Medication errors occurred in 0.15% of admissions (195 errors; one per 662 admissions). While the highest rate occurred in neonatal intensive care (0.98%), most errors occurred in medical wards. Nurses were responsible for most reported errors (59%). Errors involving the intravenous route were commonest (56%), with antibiotics being the most frequent drug involved (44%). Fifteen (8%) involved a tenfold medication error. Although 18 (9.2%) required active patient intervention, 96% of errors were classified as minor at the time of reporting. Forty eight per cent of parents were not told an error had occurred. The introduction of a policy of double checking all drugs dispensed by pharmacy staff led to a reduction in errors from 9.8 to 6 per year. Changing the error reporting form to make it less punitive increased the error reporting rate from 32.7 to 38 per year. The overall medication error rate was low. Despite this there are clear opportunities to make system changes to reduce error rates further.
Medication errors in a paediatric teaching hospital
in the UK: ﬁve years operational experience
L M Ross, J Wallace, J Y Paton
Background—In the past 10 years, medi-
cation errors have come to be recognised
as an important cause of iatrogenic dis-
ease in hospital patients.
Aims—To determine the incidence and
type of medication errors in a large UK
paediatric hospital over a ﬁve year period,
and to ascertain whether any error pre-
vention programmes had inﬂuenced error
Methods—Retrospective review of medi-
cation errors documented in standard
reporting forms completed prospectively
from April 1994 to August 1999. Main out-
come measure was incidence of error
reporting, including pre- and post-
Results—Medication errors occurred in
0.15% of admissions (195 errors; one per
662 admissions). While the highest rate
occurred in neonatal intensive care
(0.98%), most errors occurred in medical
wards. Nurses were responsible for most
reported errors (59%). Errors involving
the intravenous route were commonest
(56%), with antibiotics being the most fre-
quent drug involved (44%). Fifteen (8%)
involved a tenfold medication error. Al-
though 18 (9.2%) required active patient
intervention, 96% of errors were classiﬁed
as minor at the time of reporting. Forty
eight per cent of parents were not told an
error had occurred. The introduction of a
policy of double checking all drugs dis-
pensed by pharmacy staV led to a reduc-
tion in errors from 9.8 to 6 per year.
Changing the error reporting form to
make it less punitive increased the error
reporting rate from 32.7 to 38 per year.
Conclusion—The overall medication
error rate was low. Despite this there are
clear opportunities to make system
changes to reduce error rates further.
(Arch Dis Child 2000;83:492–497)
Keywords: children; medication errors
The United States Pharmacopeia deﬁnes medi-
cation errors as any preventable event that may
cause or lead to an inappropriate medication
use or patient harm while the medication is in
the control of the health care professional,
patient, or consumer.
A number of types of
medication errors, such as prescribing errors or
medication administration errors, have been
The various categories are not
mutually exclusive because the origins of errors
are often multiple.
In the past 10 years, medication errors have
come to be recognised as an important cause of
iatrogenic disease in hospital patients.
many errors are minor, those associated with
morbidity and mortality increase health care
costs and can be a source of litigation. Much of
the published information documenting the
incidence and type of medication errors occur-
ring in patients in hospitals comes from North
There, paediatrics ranked sixth
among 16 medical specialties in frequency of
medication related litigation claims. However,
paediatrics had twice the average reported set-
tlement of other specialities at $292 136 per
Despite this, and apart from case reports,
advice, and guidelines, little has been published
on medication errors in children in hospital.
The situation in the UK seems strikingly dif-
ferent overall, with little published data on
medication errors in any age group. There is no
national requirement that hospitals should
evaluate iatrogenic errors and many hospitals
apparently have no systems in place for the sys-
tematic recording of medication errors.
At the Royal Hospital for Sick Children,
Glasgow, Scotland, a hospital wide medication
error reporting system has been in place for ﬁve
years. During this time, the hospital Audit
Committee has reviewed aggregated error data
and promulgated a number of changes in an
attempt to reduce errors. In the present study,
we reviewed the incidence and type of errors
reported in the ﬁve years since the scheme was
established and the impact of the changes
made. We were particularly interested in com-
paring data from a routine error review system
in a hospital in a nationally funded universal
health care system with data from the insur-
ance based health system prevalent in North
Subjects and methods
This study reviewed data collected in the Royal
Hospital for Sick Children (RHSC), Glasgow
and its adjacent tertiary referral neonatal
intensive care unit (NICU) in the Queen
Mother’s Maternity Hospital. The hospital is
one of the largest paediatric teaching hospitals
in the UK with 303 inpatient beds (12 paediat-
ric intensive care (PICU), 146 medical, and
145 surgical). There is also a paediatric emer-
gency department seeing 34 000 cases annu-
ally and a maternity unit with 3600 deliveries a
year. The associated neonatal unit has 28 cots.
A hospital wide medication error reporting
policy was established at RHSC, Glasgow in
February 1994 with reporting beginning in
April 1994. The medication error policy
applied in all areas of the hospital and was
Arch Dis Child 2000;83:492–497492
Department of Child
Health, University of
Hospital for Sick
NHS Trust, Glasgow
G3 8SJ, UK
L M Ross
Hospital for Sick
Accepted 13 July 2000
mandatory for all staV, failure to report an
error being considered a disciplinary matter.
The policy also deﬁned what constituted a
medication error (listed in the Appendix).
Reports were collected on standardised forms
available in all departments; all error reports
were then investigated by the head of depart-
ment. The director of pharmacy prepared a
quarterly summary report that was submitted
to the Hospital Board, Management Group,
and the Clinical Audit Committee.
In the present study, we reviewed all errors
reported and the associated investigations
between April 1994 and August 1999.
Data were summarised using standard descrip-
tive methods. Error rates were calculated using
either aggregated monthly admission rates or
total bed days as the denominators.
A total of 195 errors were reported over a 65
month period. The occurrence of errors varied
little over the ﬁve years (table 1).
An attempt was made to ascertain the
amount of drugs administered over the time
period of the study. Unfortunately, the hospital
does not have a computerised prescribing
system and no data on the total number of pre-
scription orders are available. However, the
total number of antibiotic vials ordered by
pharmacy in the ﬁrst and last years of the study
were similar (81 312 versus 80 478 vials), sug-
gesting that major changes in the numbers of
drugs prescribed are unlikely.
Between April 1994 and March 1999 (the
latest date for which inpatient statistics are
available) there was a total of 112 536
admissions and 335 835 patient bed days.
During the same period, there were 2602
admissions to PICU, resulting in 9959 bed
days. There were 3373 admissions to NICU,
resulting in 28 796 bed days. During the same
period, 170 errors were reported, giving an
overall error rate of 0.15% admissions (one
error per 662 admissions) or 0.51 per 1000 bed
days (one error per 1976 bed days). Reported
error rates varied between each department
(table 1), being highest in the NICU (0.98%)
and PICU (0.77%). Non-intensive care areas
had lower rates (medical unit 0.22%) with the
lowest rate reported in the surgical unit
Figure 1 illustrates the age distribution of
patients involved. Eighty six (44%) of the
errors occurred in children under 2 years of
age. One ﬁfth of all errors occurred in patients
during the ﬁrst month of life. The error rate in
other age groups was more evenly spread.
The majority of errors, 115 (59%), occurred
in medical wards. Of the remainder, 25 (13%)
occurred in surgical wards, 33 (17%) in NICU,
20 (10%) in PICU, and two (1%) in theatre.
Nursing staV reported most errors (115; 59%),
reﬂecting the fact that most drugs are now
given by nurses. Medical staV, either alone or
in conjunction with another member of staV,
made 41 (21%) errors. Pharmacy dispensing
staV were responsible for 39 (20%) errors.
Most errors, 130 (67%), occurred despite
checking by two people, but in 58 (30%) cases
double checking did not occur, while in seven
(3%) it was not known whether checking
occurred or not.
Table 2 lists the types of errors. Eight
incidents involved more than one category.
Fifty six per cent (109) of the 195 incidents
involved drugs given via the intravenous route.
Table 3 proﬁles the intravenous drugs involved.
Oral medication errors occurred in 66 (34%)
cases, while other routes accounted for 20
Fifteen (8%) incidents involved a tenfold
error, of which ﬁve occurred because of miscal-
culation of dose despite clear prescribing. Four
Table 1 Date and clinical area where errors occurred
Date 4/94–1/95 2/95–1/96 2/96–1/97 2/97–1/98 2/98–1/99 2/99–8/99 Total
Medical 19 20 7 33 22 14 115
Surgical 5 5 1021225
Figure 1 Age of children involved in medication error.
1 mth–2 y
n = 42
n = 33
n = 31
> 10 y
n = 43
n = 2
< 1 mth
n = 44
Table 2 Type of error
Classiﬁcation of error No. (%)
Incorrect intravenous infusion rate 32 (15.8)
Incorrect dose administered 30 (14.8)
Extra dose given 28 (13.8)
Dose omitted 25 (12.3)
Incorrect drug given 25 (12.3)
Incorrect intravenous concentration 21 (10.3)
Labelling error 20 (9.9)
Incorrect route of administration 9 (4.4)
Incorrect patient 8 (3.9)
Incorrect strength 1 (0.5)
Other 4 (2)
Table 3 Types of intravenous drug involved in reported
Type of drug involved n (%)
Antibiotic/antiviral 48 (44)
Parenteral nutrition/intravenous ﬂuids 18 (16.5)
Anticancer drugs 11 (10.1)
Inotropes 6 (5.5)
Morphine 5 (4.6)
Steroids 5 (4.6)
Insulin 4 (3.7)
Other 12 (11)
Medication errors in a paediatric teaching hospital 493
were caused by incorrect or unclear prescribing
and one was a result of inaccurate verbal
communication. Five of the 15 arose because of
errors setting the rate on an infusion pump.
There were 23 intravenous pump errors with
between three and six per year; the rate did not
change with time. In 1994, there were 16
diVerent types of syringe pump and seven
diVerent types of volumetric pump in use
throughout the hospital. Currently, there are
still 16 types of syringe pump (a maximum of
six in any one department) and four types of
volumetric pump in use.
Medical staV assessing patient outcome clas-
siﬁed 96% of errors as minor—that is, no
actual harm resulted. Three were classiﬁed as
of medium severity (clinical symptoms were
aggravated by the error), while only two (1%)
were classiﬁed as serious (there was potential
severe harm). There were no cases of long term
morbidity or mortality. Of the two errors clas-
siﬁed as serious, one involved the administra-
tion of the wrong concentration of a chemo-
therapeutic agent, while in the other the rate of
infusion of a major sedative was 100 times too
high. Although only 4% of errors were
classiﬁed as other than minor, 18 (9.2%) errors
required active patient intervention: 10 in-
volved blood sampling, for example, electrolyte
or glucose monitoring, or drug concentration
measurement; and four required another drug
to be administered to mitigate the error (two
children received hydrocortisone and chlo-
rpheniramine, one intravenous naloxone, and
one intravenous frusemide).
Analysis of the reporting forms showed that
48% of parents were not informed that an error
had taken place.
During the period under review, there have
been a number of changes in training and
practice around drug administration. From
August 1994, a junior doctor induction pro-
gramme was introduced covering practical
aspects relevant to their job. This programme
included instruction by a senior paediatric
pharmacist on good prescribing practice.
Paediatric formularies were supplied to all jun-
ior staV. From August 1997, intravenous train-
ing has also been provided to all junior medical
staV from commencement of employment,
concentrating mainly on the preparation of
chemotherapeutic agents. Reported errors in-
volving doctors have varied slightly from year
to year, being six per year at the start and three
per year at the end.
Since January 1996, it has been pharmacy
policy that two people should check all drug
dispensing. In the 22 month period before this
time, 18 reported errors were attributed to
drug dispensing—that is, 9.8 errors per year.
The majority of these were labelling errors that
were detected and prevented by nursing staV
before administration. Only 21 occurred (six
per year) in the subsequent 43 months.
In May 1998, increased training was pro-
vided for all nursing staV initiating intravenous
drug administration. Before May 1998 a total
of 152 errors occurred (37 per year on
average). In the subsequent period, only 43
errors were reported (32 per year) despite a
gradual shift from medical to nursing adminis-
tration of intravenous drugs.
The error report form was modiﬁed in Feb-
ruary 1996 to appear less punitive in order to
encourage those responsible to reﬂect on why
the error occurred and how it might have been
prevented. In addition, a quarterly feedback
session on errors occurring during the previous
three months was instituted. Following these
changes the reported errors rose from 32.7 to
38 per year (60 errors in the 22 month period
before and 135 errors in the 43 months after).
Errors involving morphine sulphate are
potentially lethal in paediatrics. Five such
errors occurred before July 1998, leading to a
number of changes being instituted. Prior to
this date, 10 mg, 15 mg, and 30 mg ampoules
were available. In one case ampoules had been
confused, resulting in the wrong dose being
given. At this time, it was decided that only the
10 mg ampoule strength would be stocked.
The NICU changed to using syringes of
morphine preconstituted by pharmacy staV,at
a concentration of 50 µg/ml. In addition, all
morphine constitution and administration had
to be checked by two people. There have been
no further errors involving morphine reported
In this study, we reviewed ﬁve years of
medication errors, reporting data from a large
UK children’s hospital. A total of 195 errors
were reported at a rate of 0.15% of admissions
(one error per 662 admissions) or 0.51 per
1000 bed days (one error per 1976 bed days).
This rate is low compared to most published
ﬁgures. Adverse drug events in 3.7–17% of
admissions have been reported in hospitalised
adult patients in the United States.
published data relate to all adverse drug events,
including incidents such as side eVects and
potential drug errors. It is recognised that
somewhere between one ﬁfth and one quarter
of errors may be intercepted and corrected
before any drugs are administered to pa-
There is little data on errors in children in
hospital. Raju et al reported iatrogenic medi-
cation error rates of 14.7% of all admissions to
a PICU and NICU over a four year period,
while Vincer et al found 13.4 incidents per
1000 patient days over two years in an NICU.
In contrast, in a paediatric emergency depart-
ment treating 55 000 children annually, Selbst
et al found only 33 medication incidents in ﬁve
+ Medication errors are uncommon
+ There is a need to change the culture
towards recognising and acknowledging
clinical errors, including drug errors
+ Careful review of errors highlights many
opportunities for change to make drug
errors less likely
494 Ross, Wallace, Paton
These variations in error reporting rates
highlight the diYculties in making valid
comparisons of reported error rates between
studies. Such diYculties have been highlighted
in previous studies.
Some of the points made
are worth stressing. Our reporting system was
mandatory. Leape et al emphasised the inﬂu-
ence that fear of punishment may have on error
reporting and the improvement that may follow
if immunity from disciplinary action is oVered.
Similarly, we observed an increase in error
reporting after system changes which de-
creased punitive aspects and encouraged re-
ﬂection on the cause of errors. Vincer et al also
reported a substantial increase in the reporting
of medication incidents after a change to a less
It should, however, be recog-
nised that voluntary systems may also detect
only a fraction of medication errors.
intensity of the search for errors is also likely to
have an eVect. Other studies have used much
more intensive case ﬁnding mechanisms.
study looked at data from a routine reporting
system and did not make any additional eVort
to detect errors.
Although the rate of reported error was low,
many of the errors were similar to those found
in other studies. Most errors occurred in the
medical wards where the majority of drugs are
administered. Nurses reported more errors
than any other health care professional, in
keeping with previous data.
In our hospital,
this partly reﬂects the fact that nurses are
increasingly responsible for giving all medica-
tions, precisely because they have better error
trapping systems in place. The types of error
and the drugs involved were also similar to pre-
12 14 18
A type of error that may be particularly
important in children is that caused by tenfold
errors. We found 8% of the reported errors
were of this type. The importance of checking
calculations and of avoiding decimal points
where possible has been emphasised.
In 48% of cases parents were not informed.
We thought this ﬁgure was high. Selbst et al
reported that one third of families were not
made aware of the error.
The reporting form
used in this study asks if parents were notiﬁed,
and if not, to specify a reason. In many cases
the comment was that it was felt inappropriate
to notify, for example, pharmacy labelling
errors identiﬁed prior to the drug being given.
In other cases, the reasons given included the
fact that the child came to no harm, or that the
parents were not readily available at the time
and to raise the error subsequently was thought
likely to cause undue stress.
Virtually all the publications on medication
errors identify opportunities for systematic
changes to reduce the risk of future errors. All
too often, the prevalent culture is one of blame
and punishment. Our ﬁnding that 96% of
reported errors were classiﬁed as minor while
9.2% required active intervention may perhaps
be interpreted as in keeping with downplaying
incidents as a result of fear of subsequent
repercussions. The consequent reluctance to
acknowledge errors openly may result in
system failures being missed.
Most errors are not a result of individual
negligence but arise more from systemic
organisational failures. Leape et al have empha-
sised the importance of a systems based
approach where the emphasis shifts from the
individual making the error to the characteris-
tics of the system within which they function.
We found a number of examples where focus-
ing on understanding why errors occurred pro-
vided opportunities for change to make errors
less likely in the future. The importance of
hospital wide standardisation is well illustrated
by our experience with morphine sulphate. Our
failure to reduce and standardise the number of
intravenous syringe pumps in use can only give
cause for concern.
The medical profession in the UK has come
rather late to admitting openly that adverse
medical incidents including medication errors
are an important problem. But it is likely that
only by understanding and modifying the
underlying causes will we be able to reduce
future errors. Our own experience suggests that
opportunities for improvement are not diYcult
to ﬁnd in paediatric practice.
JYP suggested the idea for the paper. JW established and main-
tains the reporting system. LR collected the data, performed the
data analysis, and wrote the ﬁrst draft. LR and JYP prepared the
ﬁnal draft which all authors reviewed and approved. LR and JYP
are the guarantors for the paper.
Types of medication error requiring to be
reported in RHSC, Glasgow
+ The wrong medicine is given
+ The wrong dose of medicine is given
+ Medication is given in the wrong concentration, in
the wrong ﬂuid, or at the wrong rate (wrong prepara-
+ Medicine is administered signiﬁcantly outwith the
prescribed timeframe when there are no extenuating
circumstances (wrong time)
+ Wrong route of administration is used
+ Medication prescribed is likely to produce a known
allergic reaction (risk of allergic reaction)
+ Medication is given but not prescribed (unauthorised
drug), or prescribed but not given (omission)
+ The medication is given to the wrong person
+ Dispensed medicine is labelled wrongly (wrong label-
+ Wrong medicine or strength of medicine is dispensed
for the patient’s use at home (wrong dispensing)
+ Any of the above occurs with radiological contrast
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Medication errors in a paediatric teaching hospital 495
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Child Health 1992;28:309–11.
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Medication errors in neonatal and paediatric intensive-care
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in a pediatric emergency department. Pediatr Emerg Care
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SIZE OF THE PROBLEM
Ross and colleagues describe one medication
error (the wrong medicine, the wrong dose, the
wrong preparation, the wrong route, the wrong
time, or to someone known to be allergic) for
every 660 admissions. Ten per cent required an
intervention and one “medium/serious” error
(clinical deterioration) occurred every 13 000
admissions. There were 1 104 958 admissions
aged 0–15 years in one year in England.
one would expect at least 1675 avoidable
medication errors occur per year in paediatric
inpatients in England, of which 85 are
moderate/severe reactions. The numbers are
probably higher. The authors discuss why a
voluntary and punitive system is likely to lead
to under reporting, particularly for drugs
prescribed unlicensed or oV label.
the audit is conﬁned to inpatients. In my
medical outpatients outnumber inpa-
tients by over 3:1 and children attending A&E
with medical problems and not admitted
outnumber those admitted by over 3:1.
There were no deaths attributable to medi-
cation errors in the Scottish study but deaths
do occur and receive wide media coverage and
undermine public conﬁdence. Over a six year
period, errors in prescribing, monitoring or
administering drugs accounted for 25% of set-
tled medical negligence claims against general
WHAT CAN THE INDIVIDUAL DO?
The following should help to avoid medication
+Avoid decimal points
+ If decimals are unavoidable, use a leading
zero before the decimal point; avoid trail-
ing zeroes after the decimal point
+ Spell micrograms and nanograms in full
+ Avoid abbreviations
+ Doctors with poor handwriting should
+ Do not prescribe or prepare drugs in the
middle of the ward round—retire to a
quiet dedicated area and check all calcula-
tions with a calculator.
+ Follow your local code of practice.
HOW CAN WE CHANGE THE ORGANISATION?
DiVering infusion pumps cause confusion.
Errors appeared to increase when the service
was busiest. During an audit in Nottingham,
20 neonatal drug checks were observed during
which there were 57 interruptions by other
staV or alarms.
Prescriptions and calculations
should be double checked (30% were not in the
study of Ross et al). Errors appeared to
decrease after increased training was provided,
although this is always open to confounding in
an uncontrolled longitudinal study. Parents
must be told about medication errors (only
48% were informed in this study).
WILL MEDICINES FOR CHILDREN HELP?
The fewer calculations the better (ﬁve of the
incidents involving a tenfold error were a result
of miscalculation). Medicines for children
pliﬁes paediatric dosing by using standardised
age bands agreed throughout the European
The formulary uses mg/kg or µg/kg
doses throughout and gives the individual dose
and frequency rather than the “total daily
dose” which then requires another calculation.
A dosing or concentration mistake accounted
for 40% of the errors. The provision of drugs in
appropriate concentrations and formulations
would help avoid some of these errors and the
Medicines Control Agency is aware of this. A
centralised intravenous administration service
(CIVAS—all intravenous prescriptions are cal-
culated and constituted by a pharmacist)
operates in one of the Nottingham hospitals
during “oYce hours”. A recent consultation
document recommended that traditional work-
ing practices need to be modiﬁed to provide a
quality service at all hours
and recognised that
the “demand for pharmacists to support the
developing prescribing and medicines manage-
ment agenda continues to grow”. Automatic
computerised linkage of medical records would
guarantee that if one doctor is told a child is
allergic to a drug, this is highlighted automati-
cally on all other health records. Pocket PCs give
internet access and the capacity to store 10
books on a hand held device weighing 200 g. All
children’s drug doses could be calculated using
software for automatically checking the pre-
scription. However, the handwriting recognition
software may still struggle with doctors’ notori-
Professor of Child Health,
Academic Division of Child Health,
Queen’s Medical Centre, Nottingham NG7 2UH, UK
496 Ross, Wallace, Paton
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Prognosis after seizures
It has long been held, almost as an axiom, that one seizure is not epi-
lepsy but two or more are. For this deﬁnition of epilepsy to have any
real practical importance it must be shown that the implications of
multiple seizures are signiﬁcantly diVerent from those of a single
seizure. A long term follow up study of children in New York has sup-
ported this deﬁnition (Shlomo Shinnar and colleagues. Annals of
The study included 407 children who presented with a ﬁrst, unpro-
voked seizure between October 1983 and August 1992. Mean age at
ﬁrst seizure was 6.8 years and mean period of follow up was 9.6 years.
The seizures were classiﬁed as cryptogenic/idiopathic (342 children) or
remote symptomatic (static encephalopathy, or previous brain insult;
65 children). The cumulative risk of a second seizure at one, two, ﬁve,
and 10 years after the ﬁrst was 29%, 37%, 43%, and 46%. After a sec-
ond seizure 72% had a third, 58% had a fourth, and 29% had a total of
ten or more seizures. The cumulative risk of a third seizure at one, two,
and ﬁve years after a second was 57%, 63%, and 71%. Aetiological
classiﬁcation was an important determinant of recurrence risk. In the
cryptogenic/idiopathic group 60% had no recurrence, 13% had one
recurrence, and 10% had nine or more recurrences. In the remote
symptomatic group the corresponding ﬁgures were 28%, 8%, and
32%. An abnormal EEG after a ﬁrst seizure increased the risk of hav-
ing a second. Early recurrence (within 6 months) increased the risk of
further recurrences over the ﬁrst year. Anticonvulsant treatment halved
the risk of recurrence but only in the ﬁrst three months, and it did not
inﬂuence the risk of having many (nine or more) recurrences.
In neurologically normal children there is a 60% probability that a
single unprovoked seizure will be an isolated event. After a second sei-
zure the probability of having no more falls to 28%. Of children with a
neurological deﬁcit 72% will have at least one recurrence after a ﬁrst
unprovoked seizure. Treatment may not prevent multiple recurrences.
The authors of this study conclude that treatment “suppresses seizures
but does not alter the underlying course of the illness”.
Medication errors in a paediatric teaching hospital 497