World Patient Safety Day 2025

Children, parents and families play a vital role in making health care safer.

Health services must foster a culture where families are welcomed as partners, and children are supported to participate in their own care.

Every effort should be made to ensure that children’s conditions and treatments are explained in an understandable way and to minimise their fear and pain while receiving medical care.

RCPharm support available to achieve this goal:

• Ensuring access to services: Pharmacy teams in all settings play crucial roles in supporting people to get the most from their medicines and keep well. By providing accessible healthcare, pharmacy teams help tackle health inequalities. Our campaign on tackling health inequalities can help pharmacy teams to consider how they can provide services in ways that reach currently underserved populations and deliver accessibility for everyone.
• Speak up about your concerns: Feel empowered to speak up to relevant people and organisations when you have concerns about safeguarding, malpractice, wrongdoing or safety affecting patients, or colleagues. See our raising concerns pharmacy guide.
• Identifying and recognising signs of abuse or neglect: Our safeguarding pharmacy guide provides practical information to help you protect vulnerable adults, children and young people. There’s information on identifying and recognising signs of abuse or neglect, what to do if abuse or neglect is suspected, and signposting to further information and advice.
• Communicating with parents and involving children in medicines optimisation: This PJ Learning resource supports pharmacy teams when communicating with children and their parents or carers about their children’s medicines.

Medication use in children presents unique challenges. Each step of the medication use process carries specific risks for newborns and children.

The likelihood of error increases in children: dosing of the medication is based on the child’s age and weight, requiring individual calculation each time. Even small dosing errors can pose a greater risk of harm compared to adults. This risk is further heightened by the use of unlicensed or off-label medications.

Another challenge is the limited availability of age-appropriate formulations.

Consequently, adjusting or manipulating medicines to achieve a suitable dose introduces additional risks related to stability, bioavailability and dosing accuracy.

RCPharm support available to achieve this goal:

• Identifying gaps in your knowledge and training needed: Use the RCPharm competency framework for all prescribers to document your learning, any personal formularies you work to and update your portfolio of evidence to demonstrate your prescribing competencies.
• Prescribing safely and confidently: Whether prescribing in person or remotely, use our 12-step process to prescribe safely through personal development and improving your practice. This can be found in our prescribing safely and confidently pharmacy guide.
• Responding to patient safety events: Use our patient safety professional standards to support you when responding to patient safety events. They describe good practice and provide a broad framework to support you to continually improve services, shape future services and roles and deliver high-quality care across all settings and sectors. Their implementation will improve patient safety and the quality of pharmaceutical services.
• Medicine, ethics and Practice Guide (MEP): This resource supports pharmacists to practise confidently and professionally, to use professional judgement and to develop as a professional. The MEP includes helpful information for pharmacy teams on safeguarding protecting children and young people, the supply of medicines to schools, advice on child resistant packaging, collection and purchase of medicines by children
• Adrenaline auto-injectors (AAIs): Our AAI pharmacy guide (link to be added soon) aims to support pharmacists to recognise and manage a person presenting with an anaphylactic reaction. It will also help you with prescribing and dispensing AAIs, administering adrenaline for the purpose of saving life in an emergency and supplying AAIs against requests from schools.
• Supply of salbutamol inhalers to schools: This pharmacy guide can be used to support pharmacists receiving requests from schools for salbutamol inhalers. See the supply of salbutamol inhalers to schools pharmacy guide.
• Administering medicines safely to children at home – learning from families: This PJ Learning resource highlights some common problems when administering medicines at home in three paediatric case studies. Potential solutions and best practice are presented alongside insights from parents to highlight this often-overlooked area of medicines use.
• Paracetamol use in infants and young children: Paracetamol is one of the most used medicines in children. However, reports of adverse effects associated with unintentional overdosing highlight the importance of providing parents and carers with advice on its safe use. This PJ Learning resource supports pharmacists and pharmacy teams with educating parents and carers on appropriate use of paracetamol.
• CPD: Prescribing errors in children – why they happen and how to prevent them: This PJ Learning resource highlights the potential causes of error when prescribing for children and outlines how pharmacists can support safer prescribing.
• Case-based learning: ensuring safety of oral medicines for children: This PJ Learning resource provides an overview of the risks pharmacists should be aware of regarding oral medicines for children, including how these risks can be appropriately communicated to patients and parents or carers.
• Using critical incident data to promote paediatric medication safety: a regional quality improvement initiative in Northern Ireland: This PJ Learning resource highlights findings from a mixed methods analysis of critical incident data in Northern Ireland, which produced evidence to underpin quality improvement initiatives in paediatric medication safety.
• Designing an electronic prescribing and medicines administration system in a paediatric setting: This PJ Learning resource is the first of a two-part series on electronic prescribing systems. Electronic Prescribing and Medicines Administration (ePMA) systems can reduce medication errors, but it’s essential to understand the risks, as well as the benefits, and optimise their design for use with paediatric patients.
• How to implement an electronic prescribing and medicines administration system in a paediatric setting: This PJ Learning resource is the second of a two-part series on electronic prescribing systems focuses on the implementation of new and updated systems and how to ensure that teams get the most from electronic prescribing.
• Stay up to date with the profession: Get all the latest safety alerts and clinical knowledge by signing up to our patient safety alerts and webinars. Find out more about RCPharm pharmacy alerts.
• Prescribing development programme: Enhance your prescribing practice and help build your prescribing skills and confidence with our prescribing development programme.

An accurate and timely diagnosis is the foundation on which safe medical care rests. Sick children can present very differently from adults, making paediatric diagnosis especially complex.

Diagnostic errors can include missed, incorrect or delayed diagnoses, or a failure to communicate the diagnosis to the patient or family. They can worsen patient outcomes and at times lead to prolonged or severe illness, disability, or even death, as well as increased health care costs.

RCPharm support available to achieve this goal:

• Record all your clinical activities: Including findings, interventions, referrals, reviews, consultations, diagnosis, prescribing, administering, service delivery, decisions and advice. Your records should be detailed but concise, legible, up to date and accurate. This will protect you, support other teams and improve communication. See our clinical documentation pharmacy guide to help you with why, when and where to make a clinical record.
• Improve your practice and systems through audits: Performing regular audits, for example, on your prescribing practice or service, can help you measure, review and improve your practice and patient care. We can support you in preparing for and conducting clinical audits, and with clinical governance. See our clinical audit guide and clinical governance guide.
• Provide common conditions and ailments services: Including NHS Pharmacy First (England), NHS Pharmacy First Scotland and NHS Pharmacy First Plus (Scotland) and Community Pharmacy Wales Common Ailments Service (Wales). See the our common clinical conditions and ailments services pharmacy guide.

Newborns and children are especially vulnerable to health care-associated infections (HAIs). The main causes include insufficient application of standard infection control procedures, insufficient equipment and supplies, prolonged and/or incorrect use of invasive devices, high-risk procedures, poor infrastructure, overcrowding, and underlying immune-suppressed conditions.

Sepsis remains under-recognised across all age groups, and early identification of warning signs, combined with the implementation of evidence-based care, is essential for improving outcomes.

RCPharm support available to achieve this goal:

• Antimicrobial resistance (AMR) and antimicrobial stewardship (AMS): We promote antimicrobial stewardship (AMS) for better and safer antimicrobial use. See our antimicrobial resistance and stewardship policy.
• External AMS and AMR resources (link to be added soon).

Newborns who are born too soon, too small, or become sick, face the highest risk of disability and death. Many of the conditions related to prematurity, intrapartum brain injury, severe bacterial infection or pathological jaundice, can be prevented and managed with safe care.

Improving newborn safety, especially for small and sick newborns, requires skilled health professionals, continuous training, and clear team roles to reduce errors and ensure safe care. Standardised protocols for triage, emergency response, medication use, infection prevention, and monitoring of at-risk newborns are all essential to minimise avoidable harm.

A safe care environment, including access to properly working equipment, adequate spacing, effective hygiene, and family involvement, further protects newborns from preventable risks.

RCPharm support available to achieve this goal:

• Best practice for medicines use in neonates: This PJ Learning resource provides an overview of pharmacokinetic and pharmacodynamic considerations when treating neonates, and the impacts on drug absorption, metabolism and elimination.
• Paediatric Hub – Conditions: This PJ Learning Hub provides a number of resources for pharmacists and their teams on those common conditions seen in paediatrics, such as managing fever in children, respiratory syncytial virus in children, and gastro-oesophageal reflux disease in children: identification and management.
• Paediatrics: an introduction to constipation, diarrhoea and vomiting: This RCPharm Learn module supports you to develop essential knowledge, skills, and confidence to undertake effective consultations and provide care to children and young people experiencing constipation, diarrhoea and vomiting.

The PJ Paediatric and Neonatal Health Learning Hub includes a number of helpful resources on paediatric health, which are organised within three categories:

• Medicines – covering Medicines use in children, Medicines safety in children and vaccination.
• Conditions – covering Common conditions, Dermatology, Respiratory, Ear Nose and Throat, Parasites, Cardiology and Rheumatology.
• Safeguarding and wellbeing – covering safeguarding, Transitions of care, Mental Health.

The PJ Prescribing Hub provides a series of prescribing resources, mapped to the RCPharm prescribing competency framework.

Health Services Safety Investigations Body (HSSIB)

HSSIB has published a number of patient safety investigations (and recommendations for healthcare organisations) with a focus on paediatric health. These include:

• An exploratory review of maternity and neonatal services (August 2025)
• Keeping children and young people with mental health needs safe: the design of the paediatric ward (March 2024)
• Non-accidental injuries in infants attending the emergency department (April 2023)
• Detection of jaundice in newborn babies (January 2023)
• Weight-based medication errors in children (February 2022)
• Recognition of the acutely ill infant (December 2021)
• Management of chronic asthma in children aged 16 years and under (May 2021)
• Undetected button/coin cell battery ingestion in children (July 2019)

NHS

• Martha’s Rule – is a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.
• NHS England Patient safety healthcare inequalities reduction framework
• NHS England Safeguarding
• NHS England Healthcare associated infection (HCAI) compendium of guidance and resources
• NHS Vaccinations and when to have them
• Specialist Pharmacy Services (SPS)
  • Children’s medicines: resources to support answering questions
  • Addressing medication safety inequalities across the system
  • Managing complexities of medication use across care boundaries

Primary resources for children’s health

• BNF for Children (BNFC) – is the standard UK resource for information on the use of medicines in children. It aims to provide prescribers, pharmacists, and other healthcare professionals with sound up-to-date information on the use of medicines in children ranging from neonates (including preterm neonates) to adolescents.
• NICE Clinical Knowledge Summaries (CKS) Child Health
• Medicines for children – provides pragmatic advice for parents and carers about a range of medicines and techniques to administer them to children and young people.

Other useful resources for children’s health

• BUMPS (Best Use of Medicines in Pregnancy) – is provided by the UK Teratology Information Service (UKTIS). UKTIS is a not-for-profit organisation funded by the UK Health Security Agency (UKHSA) on behalf of the UK Health Departments.
• Neonatal and Paediatric Pharmacists Group (NPPG)
  • Labelling of Dispensed Oral Medicines for Children position statement
• Children’s Society
• National Child Mortality Database (NCMD)
• WHO Medication Safety for look-alike, sound-alike medicines
• WHO World Patient Safety Day 2024 – ‘Improving diagnosis for patient safety’
• Community Pharmacy Patient Safety Group – Look-Alike, Sound-Alike Medicines resource
• Yellow Card – anyone can report an issue with a medicine, vaccine, medical device or blood product to the Yellow Card Scheme. The Yellow Card scheme is run by the Medicines and Healthcare products Regulatory Agency (MHRA), which safeguards medical products quality and efficacy in the United Kingdom.
• Toxbase – is the primary clinical toxicology database of the NPIS (National Poisons Information Service) and is a first-line resource for UK healthcare professionals providing information on the routine diagnosis, treatment and management of poisoning. TOXBASE is free of charge to UK NHS departments and practices, and also to UK military healthcare units and emergency departments and public health units within Ireland.
• UKHSA Guidance – Routine childhood immunisations from 1 January 2025 (babies born before 1 July 2024)
• UKHSA Which flu vaccines should children have?
• UKHSA Guidance – Flu vaccination programme 2025 to 2026: information for healthcare practitioners

Training

• The Oliver McGowan Mandatory Training on Learning Disability and Autism – named after Oliver McGowan, whose death shone a light on the need for health and social care staff to have better training. The Health and Care Act 2022 introduced a statutory requirement that CQC-registered providers must ensure their staff receive learning disability and autism training appropriate to their role
• NHS England Patient Safety Syllabus – the NHS-wide Patient Safety Syllabus which applies to all NHS employees and will result in NHS employees receiving enhanced patient safety training
• CPPE Child Health
• RCPharm Learn

Wales

• Improvement Cymru Strategy – 2021-2026
• Quality and Governance – NHS Wales Performance and Improvement.

England

• The NHS Patient Safety Strategy
• Patient Safety Commissioner

Scotland

• Scottish Patient Safety Programme (SPSP)
  • Delivering value-based health and care: a vision for Scotland
  • Realistic Medicine

WHO

• Global Patient Safety Action Plan 2021-2030