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

Stavroudis, Theodora A.; Shore, Andrew D.; Morlock, Laura L.; Hicks, Rodney W.; Bundy, David G.; Miller, Marlene R.

doi:10.1038/jp.2009.186

Cited by 83 publications

(99 citation statements)

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“…Often, these errors are preventable and result in increased patient morbidity and mortality as well as increased healthcare costs and unnecessary hospitalization [European Medicines Agency, 2015]. While the problem of medication errors has been widely reported in published literature, of particular concern are those that occur in neonatal medicine [Kaushal et al 2001;Fortescue et al 2003;Stavroudis et al 2010]. The neonatal population is particularly vulnerable to further risk of harm resulting from medication errors due to their physiological inability to buffer errors [Kaushal et al 2001].…”

Section: Introductionmentioning

confidence: 99%

“…The neonatal population is particularly vulnerable to further risk of harm resulting from medication errors due to their physiological inability to buffer errors [Kaushal et al 2001]. Medication errors with potential to cause harm are eight times more likely to occur in the neonatal intensive care unit (NICU) compared with adult wards [Kaushal et al 2001;Stavroudis et al 2010]. Furthermore, it is reported that medication errors comprise 84.2% of all medical errors within the NICU [Stavroudis et al 2010].…”

Section: Introductionmentioning

confidence: 99%

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Medication safety in neonatal care: a review of medication errors among neonates

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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Objective: The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum. Method: In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients. Results: A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team. Conclusion: This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Medication safety in neonatal care: a review of medication errors among neonates

Krzyżaniak

Bajorek

2016

Therapeutic Advances in Drug Safety

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“…İlaç hataları reçeteleme, dağıtım, hazırlama, uygulama ve ilacın etkilerinin izlenmesi aşamalarının herhangi birinde meydana gelebilir (15) . Ancak yapı-lan çalışmalar ve bildirimler, hem erişkin hem de çocuk hastalarda en fazla hatanın hekimlerin ve hemşirelerin sorumlu olduğu reçeteleme ve uygulama aşamasında meydana geldiğini göstermektedir (11,16,17) . Merino ve ark.…”

Section: Tanımunclassified

“…Stavroidis ve ark. (17) yenidoğan yoğun bakım üni-telerindeki ilaç hatası bildirimlerini inceleyerek yap-tıkları çalışmada, hata nedenlerini %68,4 insan faktö-rü, %14,4 iletişimsizlik, %6,7 ekipman ve ilaç uygulama cihazları olarak sıralamıştır. You ve ark.…”

Section: İlaç Hatalarının Nedenleriunclassified

Medication Errors and Reporting in Pediatrics

Gök¹,

Sarı²

2016

BUCH

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ÖZİlaç hataları, hasta güvenliğini tehdit eden ve maliyeti arttıran önemli bir sağlık sorunu olarak görülmektedir. Hatalar, ilaç hazırlamadan uygulamaya kadar pek çok aşamada meydana gelmektedir. Çocuklar kiloları, vücut yüzeyleri gibi gelişimsel özel-likleri ya da bazı ilaçların pediatrik formlarının olmaması nedeniyle daha sık ilaç hatasına maruz kalabilmektedirler. Ayrıca küçük çocukların ilaç yan etkilerini dillendirememeleri, ilaç hatalarının tespitini güçleştirmekte ve hatalardan zarar görmeleri-ne neden olmaktadır. Bu nedenle pediatrik popülasyonda ilaç hatalarının önlenmesi ayrı bir önem taşımaktadır. Hatalarının temelde iki önemli nedeni vardır; sistem faktörü ve insan faktörü. İnsan faktörü de ayrıntılı incelendiğinde asıl nedenin sisteme bağlı olduğu görülmektedir. İnsanlar doğası gereği hata yaparlar, amaç olabildiğince etkin sistemler geliştirerek hataları en aza indirmektir. Hatalarının önlenmesinde, hataların tanımlanması ve hata bildirimlerinin yapılması çok önemlidir. Hata bildirimleri, özellikle ramak kala hataların bildirilmesi kök neden analizi yapılmasına ve benzer hataların önlenmesine olanak sağlar. Ancak yapılan çalışmalar ilaç hataları-nın yeteri kadar bildirilmediğini göstermektedir.Anahtar kelimeler: Hata bildirimi, ilaç hataları, tıbbi hatalar, çocuk ABSTRACTMedication errors are major health problems that increase the cost and threaten patient safety. Medication errors, take place over several stages starting from the preparation of drugs up to pharmaceutical applications. Children may expose more frequently to medication errors, because of lack of pediatric formulations of some drugs and developmental characteristics of children such as body surface and weight. In addition, small children can not express their drug side effects which makes it difficult to determine the cause of the damage from medication errors and children become vulnerable to deleterious effects of the medication errors. Therefore, prevention of medication errors in a pediatric population is of particular importance. There are two main reasons for this fundamental error including factors related to the system, and human beings. Furthermore, when examined in detail, human factor also appears to be the main reason connected to the system. By their nature, human beings make errors, the aim is to develop effective systems to minimize errors as far as possible. For the prevention of errors, identifying, and reporting errors and bugs are very important. Error notifications, in particular the reporting of errors enables root cause analysis of near misses and allows prevention of similar mistakes. However, studies indicate that medication errors are not reported as it should be.

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“…Children have a higher risk of being exposed to medication errors and are more prone to harm due to reasons such as differences in their growth and development, and their physiological and psychological characteristics which are different from those of adults. [3] Preventable medication errors not only adversely affect human health but also increase the cost of healthcare. According to a report published in 2013, the cost of preventable medication errors in the United States (US) is at an average of $ 20 million (between 15 and 28 million dollars).…”

Section: Introductionmentioning

confidence: 99%

Reporting of medication errors by pediatric nurses

Gök

Sarı²

2017

JNEP

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Background and objective: Children have a higher risk of being exposed to medication errors and are more prone to harm due to reasons such as differences in their growth and development, and their physiological and psychological characteristics which are different from those of adults. The purpose of this study is to determine pediatric nurses' attitudes towards reporting of medication errors and causes of not reporting of medication errors and to determine their views on the incidence of medication errors. Methods: The study was conducted in a Children's Hospital in the province of Izmir, with the participation of 179 pediatric nurses. To collect the data, two forms were used in the study, socio-demographic questionnaire and Questionnaire for Medication Errors. Results: While 34.6% (n = 62) of the nurses thought that medication errors never happened in the clinics over the past year. While 94.4% (n = 169) of the participating nurses did not report any medication errors within the past year, 5.6% reported 1-2 times. The highest proportion (75.4%) (n = 135) of the nurses, the reason for not reporting medication errors was the fear of receiving legal punishment. Conclusions: Reporting medication errors is low level. In conclusion, the main reason for not reporting medication errors was the perception of receiving punishment. Implications for nursing and/or health policy: Education to nurses should be given at regular intervals and in small groups by using case samples. If the managers are to promote reporting, they should eliminate the perception of receiving punishment, and make necessary arrangements to develop non-accusatory culture aiming to learn from the results of reported errors.

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

Cited by 83 publications

References 35 publications

Medication safety in neonatal care: a review of medication errors among neonates

Medication safety in neonatal care: a review of medication errors among neonates

Medication Errors and Reporting in Pediatrics

Reporting of medication errors by pediatric nurses

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