[Medication errors: analysis of a digoxin overdose case in a neonatology unit]

Neonatology and pediatrics are units where medication errors occur. Indeed, the complexity of nursing care, the lack of information and marketing authorization for drugs contribute to the occurrence of often underestimated iatrogenic events. Through a case of digoxin overdose in a neonatology unit, each stage of the drug circuit was analyzed. From prescription to administration to dispensation, the accumulation of individual errors put a newborn in danger. The analysis and declaration of such events can improve safety and the quality of patient care.