Recent medical incidents in the United Kingdom show a worrying gap between official hospital rules and actual patient safety, particularly regarding medication mistakes in children's care.

英國近期發生的醫療事故顯示，醫院的官方守則與實際病人安全之間存在令人擔憂的差距，特別是關於兒童護理中的用藥錯誤。

The first case involves an infant who received a medication called phenytoin during a seizure at a hospital in Scotland. Although a parent, who is an experienced pediatric emergency doctor from the US, suggested using a different drug to avoid tissue damage, the hospital followed its own internal rules. This led to severe skin damage that required surgery. Surprisingly, the hospital's review concluded that no mistake was made because the staff followed the protocol. This suggests that the hospital valued following rules more than the actual health outcome of the patient.

第一個案例涉及一名在蘇格蘭醫院因癲癇發作而接受苯妥英（phenytoin）治療的嬰兒。儘管其家長是一位來自美國且經驗豐富的兒科急診醫生，建議使用另一種藥物以避免組織損傷，但醫院仍遵循其內部規則。這導致了嚴重的皮膚損傷並需要手術。令人驚訝的是，醫院的審查結論認為沒有錯誤，因為員工遵循了操作流程。這表明醫院重視遵守規則，而非病人的實際健康結果。

Similarly, a second incident involved a five-year-old patient. A physician associate (PA) prescribed a medication for a fungal infection without the proper legal authority or supervision from a doctor. Furthermore, the pharmacy failed to stop this inappropriate prescription. The Parliamentary and Health Service Ombudsman (PHSO) described these as serious failures that caused physical injury and led to unnecessary investigations into sexual abuse. As a result, the Royal College of GPs has now suggested that PAs should not treat patients under 16 to ensure better safety and supervision.

同樣地，第二起事故涉及一名五歲患者。一名醫師助理（PA）在缺乏合法權限或醫生監督的情況下，開立了治療真菌感染的藥物。此外，藥局未能攔截這份不恰當的處方。議會及醫療服務監察專員（PHSO）將其描述為嚴重的失效，造成了身體傷害並導致不必要的性虐待調查。因此，皇家全科醫生學院目前建議，醫師助理不應治療 16 歲以下的患者，以確保更好的安全與監督。

The evidence shows that simply following formal rules does not guarantee patient safety, and a lack of professional supervision continues to put children at risk.

證據顯示，單純遵循正式規則無法保證病人安全，且缺乏專業監督持續使兒童面臨風險。