Medication errors in the neonatal intensive care unit: special patients, unique issues

Abstract

Medication errors are quite common in the neonatal intensive care unit M edical errors are a common occurrence in the neonatal intensive care unit (NICU). Although this high risk, fragile patient population is prone to a wide array of errors, medication errors are particularly common. Medication errors were the most common error type submitted to the Vermont Oxford Network's NICQ.org voluntary reporting system. 1 Kaushal and colleagues 2 identified errors in 5.5% of NICU medication orders. Of note, potential adverse drug events (errors that had the potential to harm the patient but were intercepted, or potentially harmful errors that reached the patient but fortuitously did not result in injury) occurred eight times more often in NICU patients than in adults in hospital. Neonates, especially very low birthweight babies, are particularly vulnerable to adverse sequelae of medication errors as they have a limited ability to ''buffer'' such mistakes. Nursing practice has long recognised the need for extreme vigilance and a structured approach to preventing medication errors. The five ''Rights'' provide a framework for improving medication safety in nursing. These basic principles of standard operating procedure try to address all of the steps in the medication process: ordering, dispensing, administering, and monitoring drugs. Nurses attempt to ensure that the Right drug is given in the Right dose at the Right interval via the Right route to the Right patient. Although nurses focus on providing error-free care, research into human factors teaches us that dedication, training, and vigilance are not enough to prevent errors in complex systems. 3 4 Error prevention must be a multidisciplinary process, involving doctors, pharmacists, and nurses working as a team. The team must be backed up by robust healthcare delivery systems operating in a ''culture of safety'', providing staff with a working environment that provides safeguards against human fallibility. Nowhere in the hospital is the challenge greater than in the NICU.

The Impact of Rudeness on Medical Team Performance: A Randomized Trial

“…5,6 Studies suggest that the rate of iatrogenic events among hospitalized pediatric patients is substantially higher, and that the critically ill, such as those hospitalized in NICUs, are at particular risk. 2,3,7,8 Although research has tended to focus primarily on patientrelated factors (eg, age, weight), 1, [8][9][10][11] studies suggest that practitioner stressors may also heighten iatrogenic risk. [12][13][14] One such stressor may be rudeness, a relatively mild form of interpersonal aggression or incivility.…”

NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

“…[9][10][11] Neonates are a particularly vulnerable population and may be at further risk of harm from medication errors because of changing body size, weight-based dosages, off-label drug usage, availability of stock solutions in a variety of concentrations, inability to communicate with providers, and changing developmental systems affecting drug absorption, distribution, metabolism, and excretion. [12][13][14][15][16][17][18] For example, the necessary calculations involved in the ordering of medications and in the dilution of stock drugs in the NICU place these patients at risk for harm from 10-to 100-fold dosing errors. 19 Nevertheless, the understanding of medication errors affecting the care of the neonate is in its early stages, thus hampering efforts to identify targets for intervention in preventing these errors.…”

Current pharmacotherapy in the newborn

“…26 It has been observed that dedication, training, and vigilance are not enough to prevent errors in complex systems. 24 Many factors influencing the intrinsic risk of medication errors have been identified, namely intensity of workload, day shift, handovers among caregivers, lack of knowledge of the procedures, inadequate use of technology, lack of communication in the team, understaffing, inadequate training, and absence of awareness of errors. 26,32,33 Inexperience is another risk factor for medication errors.…”

“…It has been documented that potentially harmful errors intercepted before causing injury or those reaching the patient without any consequences are more frequent in NICU patients than in hospitalized adults. 24 The newborn is more vulnerable to adverse effects of medication errors due to its small size, 25 rapidly changing body surface area and weight, 23 physiological immaturity, 25 limited compensatory abilities, 25 and inability to communicate with the provider. 23 In addition, the need to calculate individualized doses and, for many drugs, the narrow therapeutic margin, increase the risk of medication errors and their adverse effects in newborns.…”

“…34 Pharmacists make mainly dispensing errors, particularly errors in reviewing the medical prescriptions and in diluting stock solutions in order to provide extremely minute doses. 24 Nurses are mainly involved in medication preparation and administration, and are specifically trained to ensure that the right drug is given in the right dose, at the right interval, via the right route, to the right patient, with the right documentation (six rights of medication administration). Nurses are exposed to commission errors when one or more of the six rights of medication administration are violated, and to omission errors when a prescribed drug is not given to the patient.…”