Abstract
Background: Medication errors are common in the neonatal intensive care unit (NICU). Various strategies to reduce errors have been described in adult and paediatric patients but there are few published data on their effect in the NICU.
Aim: To describe the medication errors occurring within an NICU, and assess the impact of a combined risk management/clinical pharmacist led education programme on these errors.
Methods: Medication errors were identified prospectively over one year by critical incident reporting. Four months into the study, a pharmacist led education programme was instituted. This involved a daily, cot side, pharmacist led review of medication orders. Each new member of pharmacy, nursing, or medical staff was also required to successfully complete a series of dose calculations. In addition, a risk management approach was used to make several changes in practice during the study period.
Results: A total of 105 errors were identified, four serious, 45 potentially serious, and 56 minor. The four serious errors included two tenfold dose miscalculations. Most (71%) of the errors were due to poor prescribing. After the introduction of our interventions, monthly medication errors fell from a mean (SD) of 24.1 (1.7) per 1000 neonatal activity days to 5.1 (3.6) per 1000 days (p < 0.001) in the following three months. The subsequent change over of junior medical staff was associated with a significant increase in medication errors to 12.2 (3.6) per 1000 neonatal activity days (p = 0.037). However, the number remained significantly less than before our interventions (p < 0.001). Three serious errors occurred in the first four months compared with one in the second eight month period, the latter corresponding to the six monthly change over of junior medical staff.
Conclusions: Medication errors are common in NICUs. Fortunately, actual harm to an infant is rare. Interventions to reduce errors, particularly within the context of a risk management programme, are effective.
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Selected References
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- Dean Bryony, Schachter Mike, Vincent Charles, Barber Nick. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002 Apr 20;359(9315):1373–1378. doi: 10.1016/S0140-6736(02)08350-2. [DOI] [PubMed] [Google Scholar]
- Folli H. L., Poole R. L., Benitz W. E., Russo J. C. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics. 1987 May;79(5):718–722. [PubMed] [Google Scholar]
- Fortescue Elizabeth B., Kaushal Rainu, Landrigan Christopher P., McKenna Kathryn J., Clapp Margaret D., Federico Frank, Goldmann Donald A., Bates David W. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003 Apr;111(4 Pt 1):722–729. doi: 10.1542/peds.111.4.722. [DOI] [PubMed] [Google Scholar]
- Frey Bernhard, Buettiker Vera, Hug Maja I., Waldvogel Katharina, Gessler Peter, Ghelfi Daniela, Hodler Catherine, Baenziger Oskar. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr. 2002 Sep 18;161(11):594–599. doi: 10.1007/s00431-002-1055-0. [DOI] [PubMed] [Google Scholar]
- Kaushal R., Bates D. W., Landrigan C., McKenna K. J., Clapp M. D., Federico F., Goldmann D. A. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001 Apr 25;285(16):2114–2120. doi: 10.1001/jama.285.16.2114. [DOI] [PubMed] [Google Scholar]
- Kaushal Rainu, Shojania Kaveh G., Bates David W. Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. Arch Intern Med. 2003 Jun 23;163(12):1409–1416. doi: 10.1001/archinte.163.12.1409. [DOI] [PubMed] [Google Scholar]
- King W. James, Paice Naomi, Rangrej Jagadish, Forestell Gregory J., Swartz Ron. The effect of computerized physician order entry on medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003 Sep;112(3 Pt 1):506–509. doi: 10.1542/peds.112.3.506. [DOI] [PubMed] [Google Scholar]
- Koren G., Barzilay Z., Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic disease in pediatrics. Pediatrics. 1986 Jun;77(6):848–849. [PubMed] [Google Scholar]
- Koren G., Reich A., Hales B. Use of clinical pharmacists to prevent medication errors in children. J Pharm Technol. 1991 Nov-Dec;7(6):219–221. doi: 10.1177/875512259100700607. [DOI] [PubMed] [Google Scholar]
- Leape L. L., Cullen D. J., Clapp M. D., Burdick E., Demonaco H. J., Erickson J. I., Bates D. W. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA. 1999 Jul 21;282(3):267–270. doi: 10.1001/jama.282.3.267. [DOI] [PubMed] [Google Scholar]
- Ross L. M., Wallace J., Paton J. Y. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000 Dec;83(6):492–497. doi: 10.1136/adc.83.6.492. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Wilson D. G., McArtney R. G., Newcombe R. G., McArtney R. J., Gracie J., Kirk C. R., Stuart A. G. Medication errors in paediatric practice: insights from a continuous quality improvement approach. Eur J Pediatr. 1998 Sep;157(9):769–774. doi: 10.1007/s004310050932. [DOI] [PubMed] [Google Scholar]