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Situation Harm to children through inadvertent under/overdosing of liquid is still happening across Regional Children Heart Disease Network (RCHDN) due to changes in liquid strength. A recent incident with propranolol liquid strength change resulted in a 10-fold underdose and child admission with Supraventricular Tachycardia (SVT), despite the RCHDN liquid strength policy and updated children’s hospital formulary. With the continuous medication incidents, the Discharge Medicines Service (DMS) communication route was investigated. DMS was implemented in 2021, allowing sharing of information between the hospital, General Practitioners (GPs) and community pharmacists at the time of discharge. 1 Studies have shown that DMS was effective in reducing medication errors, preventing 21,000 adult hospital admissions in 2022.2 To date, there is limited information on the use of DMS among children. Extrapolating from adult data, it was concluded that DMS could be used in a similar way to enhance support and improve communication in the paediatric population.3 Studies have shown that communication between tertiary care and young patients and their parents/carers is inadequate, with parents raising concerns over the type of medication, indication, side effects, or ways of obtaining a repeat prescription.4 Children with cardiac disorders at the Regional Cardiac Centre would benefit from the implementation of DMS as they require precise dosing and continuity of liquid strength to avoid parental confusion and administration errors. DMS can be a useful communication platform, with the aim to increase medication safety and improve health outcomes.In January 2025, DMS was launched for children with cardiac disorders at the children’s hospital to convey instructions to community pharmacists on the provision of standard liquid strengths as stipulated in RCHDN policy. This service was audited over a 3-month period, looking at the completion of DMS and compliance of primary care with the RCHDN recommendations. 71 children were discharged from the children’s cardiac ward on cardiac medications. Nominated community pharmacies was documented for 11% (n=8/71), DMS was sent to 6% (n=4/71) of patients. Among those, 75% (n=3/4) of patients continued liquid strengths as recommended by RCHDN liquid strength policy, whilst 1 patient stopped their medications.Lessons Learnt The DMS is a useful service for communicating the strength of liquid medication for children with cardiac disorders discharged from tertiary care to primary care, ensuring that prescribing and dispensing of liquid strength information is communicated across healthcare boundaries (tertiary-secondary-primary care). The DMS communication route for ensuring the continuation of the same liquid medication strength was successful with a small number of participants. The next step to improve uptake will include collaboration with the children’s hospital pharmacy team, ensuring children have a nominated community pharmacy and completion of the DMS on discharge. Then the audit would be repeated, with a larger cohort. Ultimately, the aim would be to use DMS for communicating the strengths of liquid medications for all children in the children’s hospital.References National Pharmacy Services [Internet, accessed 24.06.25:]. Community Pharmacy England. Available from: https://cpe.org.uk/national-pharmacy-services/ Perkins L. Discharge medicines service has prevented almost 22,000 hospital readmissions, government says [Internet, accessed 24.06.25:]. The Pharmaceutical Journal. 2023. Available from: https://pharmaceutical-journal.com/article/news/discharge-medicines-service-has-prevented-almost-22000-hospital-readmissions-government-says Trivedi A, Bhatti A, Patel B, et al. What’s age got to do with it? A study of the implementation of the discharge medicines service for paediatric patients. International Journal of Pharmacy Practice 2024;32(3):229–236.Aston J, Wilson KA, Terry DRP. The treatment-related experiences of parents, children and young people with regular prescribed medication. International Journal of Clinical Pharmacy 2019;41(1):113–21.