Through its core work to review recorded patient safety events, the National Patient Safety Team identified an incident of unintentional overdose of a phosphate supplement to a baby, resulting in seizures. Phosphate supplements help to correct phosphate levels in cases where blood levels are low.
The report described a baby requiring treatment for seizures after being given effervescent phosphate tablets at a sixteen times higher dose than intended. A search of the National Reporting and Learning System identified 23 reports, over three years, relating to use of phosphate or calcium effervescent tablets in children.
As no oral liquid calcium or phosphate products are licensed in the UK, portions of effervescent tablets are sometimes used to administer these supplements to children; this complex process is prone to error.
Collaboration between the National Patient Safety Team and partner organisations led to the publication of a suite of resources and the delivery of a webinar to the national Medication Safety Officer network:
- Neonatal and Paediatric Pharmacy Group Position Statement: Enteral Calcium and Phosphate Supplementation in Neonates and Children (Royal College of Paediatrics and Child Health / NPPG Medicines Committee)
- Managing the risks of using effervescent tablets in children – SPS – Specialist Pharmacy Service
- How to give phosphate or calcium from effervescent tablets (Medicines for Children)
- Revision of BNFC monographs for calcium carbonate and phosphate
These new resources will support safer dosing and administration of calcium and phosphate supplementation in children.
Publication reference: PRN01208