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which is likely to be in response to a higher energetic cost of foraging in eiders. It is 43 possible that increased resting in both diving and dabbling ducks reduces their likelihood 44 of detection by predators, while allowing them to remain vigilant. We demonstrate that 45

The use of the fentanyl skin patch to provide pain relief in chronic pain conditions and oncology in adult practice has been common for several years, and an increase in use is now being seen in pediatric practice. Its use in drug misuse and suicide has also increased in recent years. We present the case of an adolescent who deliberately overdosed using fentanyl skin patches and describe the implications for management. This report serves to remind clinicians to consider this method of drug administration in children who display signs of opioid toxicity, where overdose may be subsequent to its use in therapy, recreation, or deliberate self-harm.

Objective To determine the accuracy and reproducibility of methods used in practice to measure small dose volumes commonly used in the Paediatric Intensive Care Unit (PICU). Method Nursing staff were surveyed to determine how they would measure two different volumes of insulin for subsequent dilution in 50 ml of a diluent to produce 2.5 and 5 units in 50 ml. Four methods were identified. In Methods A and B a small excess of volume was drawn into the 1 ml syringe via a filter needle, which was then removed. Method A, the excess was removed leaving the volume required in the syringe then a needle was attached prior to transfer to the 50 ml syringe. Method B, the needle was primed by attaching the needle prior to expelling excess. Methods C and D involved initially diluting 0.5–5 ml, method D different by priming the needle prior to transferring the volume required into the 50 ml syringe. Simulations of each method were repeated 10 times in a pharmaceutics laboratory to determine their accuracy. Weights were used to quantify methods A and B; UV spectroscopy was used to assess the concentration of the final dilution of methods C and D. Results are expressed as mean percentages (±SEM) of simulated insulin doses. Results For method A, both 2.5 and 5 unit measurements consistently yielded the equivalent of zero units. In method B attempts to measure 2.5 units produced an average of 2.7±0.26 units and 5 units resulted in 5.23±0.5 units. In method C attempts to measure 2.5 units yielded 1.8±0.74 units and 5 units resulted in 3.5±0.98 units. In method D attempts to measure 2.5 units yielded 2.4±0.59 units, and 5 units gave 5.58±0.28 units. Conclusion The methods described to deliver small volume doses of insulin on PICU provide inaccurate final concentrations. The inability to reproduce accurate concentrations for each dose could have significant clinical effects for the PICU patient, especially for drugs with a narrow therapeutic index for example, insulin.1 2 Dilution methods are generally considered to be more accurate.3However, this small study indicates that for volumes of ≥0.05 ml a direct withdrawal method may be more accurate, but a dilutional method produces a better reproducibility. However the present study must be extended for confirmation. This study also highlights the need for detailed protocols for measuring small volumes to avoid inter-personnel variation.

Aims The aim of this study was to assess the incidence, nature, preventability and severity of adverse drug events (ADEs) across three paediatric intensive care units (PICUs) in England. Methods A prospective observational cohort study was conducted across three PICUs over a three‐month period during 2019. Included patients were aged ≤18 years and stayed in PICU for a minimum of 24 hours. Identification of suspected ADEs was performed by trained PICU pharmacists. A multidisciplinary expert panel assessed causality, preventability and severity of events. Results A total of 302 patients were included and 62 ADEs were confirmed (definite/probable causality). One in six patients experienced one or more ADEs. The estimated incidence of ADEs were 20.5 per 100 patients (95% CI 15.3–27.5) and 16.7 per 1000 patient‐days (95% CI 9.3–29.9). The majority of ADEs were judged preventable by the expert panel (36/62, 58.1%). ADEs were commonly involved with medicines prescribing (29/62, 46.8%) and caused temporary patient harm (42/62, 67.7%). Medications for the central nervous system (14/62, 22.6%), infections (13/62, 20.9%) and cardiovascular system (12/62, 19.4%) were commonly implicated with ADEs. Multivariable analysis revealed that patients who stayed in PICU for ≥7 days (OR 6.29, 95% CI 2.42–16.32) were more likely to experience an ADE compared to patients with a stay of 1–6 days. Conclusion ADEs are common in English PICUs and most of them may be preventable. There is a strong association between ADE occurrence and duration of PICU stay, which represents a target for remedial interventions. Exploring contributory factors of preventable ADEs is now necessary to inform preventive policies.