The case report Harm to a child caused by the off-label use of prochlorperazine maleate tablets due to the discontinuation of licensed prochlorperazine mesilate liquid in the UK shares a family’s experience with our healthcare system. It highlights the importance of viewing healthcare from the perspective of its users, especially when multiple services and professionals are involved, sometimes leading to patients falling through the gaps.
This case was triggered by a seemingly benign event: changing a child’s medicine from the liquid, which was no longer available, to the tablet version. This change led to the family struggling to control their son’s vomiting and their lives being disrupted by multiple hospital admissions and treatments. The situation improved when they spent time with a pharmacy professional specialising in children’s medicines, agreeing a new treatment plan together. This was effective in controlling his vomiting so that he could complete his treatment.
The NHS has robust system for recording harm and learning from events. However, there are gaps in the system, where patients are harmed and learning is lost. By highlighting these issues, the authors hope to prompt further work in this area and provide additional resources for families managing medicines at home.
Co-authors Andy and Vicki Salm are the parents involved in this case. Lead author Stephen Morris (National Institute for Health and Care Research (NIHR) Doctoral Fellow and Specialist Clinical Pharmacist) stresses that this is their family’s story to share and reminds us that illness stories belong to people using healthcare services, not to professionals or the establishment. By working together, these stories can be articulated and shared to unlock the learning within them.
To establish a relationship and build trust between everyone involved in a case report, Stephen stresses the importance of being open about why you want to write it, what you will write in the report, and what impact you hope it will have. Whilst the time it takes to write it up can be challenging, having a clear aim and strong relationship between authors is invaluable.
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