Date published: 23 July, 2024
Date last updated: 24 July, 2024
Patient safety

Use of effervescent tablets to administer doses of calcium and phosphate supplements to children

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

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:  

These new resources will support safer dosing and administration of calcium and phosphate supplementation in children.

Publication reference: PRN01208

Date published: 23 July, 2024
Date last updated: 24 July, 2024