Identifying medication errors in neonatal intensive care units: a two-center study

Abstract

BackgroundThis study aimed to assess the types and frequency of medication errors in our NICUs (neonatal intensive care units).MethodsThis descriptive cross-sectional study was conducted on two neonatal intensive care units of two hospitals over 3 months. Demographic information, drug information and total number of prescriptions for each neonate were extracted from medical records and assessed.ResultsA total of 688 prescriptions for 44 types of drugs were checked for the assessment of medical records of 155 neonates. There were 509 medication errors, averaging (SD) 3.38 (+/− 5.49) errors per patient. Collectively, 116 neonates (74.8%) experienced at least one medication error. Term neonates and preterm neonates experienced 125 and 384 medication errors, respectively. The most frequent medication errors were wrong dosage by physicians in prescription phase [WU1] (142 errors; 28%) and not administering medication by nurse in administration phase (146 errors; 29%). Of total 688 prescriptions, 127 errors were recorded. In this regard, lack of time and/or date of order were the most common errors.ConclusionsThe most frequent medication errors were wrong dosage and not administering the medication to patient, and on the quality of prescribing, lack of time and/or date of order was the most frequent one. Medication errors happened more frequently in preterm neonates (P < 0.001). We think that using computerized physician order entry (CPOE) system and increasing the nurse-to-patient ratio can reduce the possibility of medication errors.

Nursing leadership styles and their impact on intensive care unit quality measures: An integrative review

“…One study (Vogus & Sutcliffe, 2007) included in this review indicates that leadership styles are associated with medication errors. Medication errors are a key outcome measure because they occur commonly in ICUs (Eslami, Aletayeb, Aletayeb, Kouti, & Hardani, 2019). It has also been established that fairness and integrity are important for discerning patterns in the occurrence of medication errors (Vogus & Sutcliffe, 2007).…”

Caracterização da produção científica sobre erro no trabalho em saúde

“…(17) Dentre os erros na terapia medicamentosa, a dosagem incorreta prescrita por médico (28%) e a não administração de medicamento pela(o) enfermeira(o) (29%) foram as etapas citadas como erro mais frequente em unidades de terapia intensiva neonatal. (18) Em estudo realizado em um hospital universitário francês e em uma unidade de terapia intensiva nos EUA, identificou-se que os erros de prescrição de medicamentos, cometidos por médicos, estão entre os que mais ocorrem nos serviços de saúde e são considerados graves. (19,20) De modo geral, as pesquisas sobre erro no trabalho em saúde ocorreram em hospitais.…”

“…Quanto aos elementos do contexto para a ocorrência do erro, destaca-se a inexperiência da equipe de saúde, registro ilegível de prescrições, uso de abreviaturas, tempo de formação profissional inferior a dois anos, déficit no conhecimento, estresse, distração e profissionais mais jovens, sendo estes fatores relativos a características individuais dos profissionais. (18,(25)(26)(27)(28)(29) Já em outros estudos, (30)(31)(32)(33) revelou-se a precarização do trabalho. A precarização do trabalho é um sistema político que visa à dominação e à disseminação do medo, criando um contexto de insegurança permanente no trabalhador, submetendo-o à exploração.…”

Medication Errors in Pediatrics: Proposals to Improve the Quality and Safety of Care Through Clinical Risk Management

“…Nichter et al observed an incidence of medication errors in pediatric intensive care units ranging between 22 and 59 errors per 1,000 doses, seven times more frequently than other pediatric inpatient units (16). Furthermore, the reported risk of medication errors in neonatal wards is eight times higher than that of adults' ones (17,18). An incidence ranging between 13 and 91 medication errors per 100 admissions in the Neonatal Intensive Care Unit (NICU) has been estimated with rates of occurrence considerably higher in preterm neonates (75.4 vs. 24.6%) (19).…”