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Medication error in an extremely low birth weight infant: paracetamol overdose
Pablo Brener1, Mónica Ballardo, Gonzalo Mariani
1Division of Neonatology, Department of Pediatrics, University Institute, Hospital Italiano de Buenos Aires. pablo.brener@hospitalitaliano.org.ar
Archivos Argentinos De Pediatria
|February 6, 2013
Summary
A medication error occurred when a preterm infant received 20 times the required dose of paracetamol. Prompt administration of N-acetylcysteine led to a satisfactory outcome, highlighting the need for enhanced patient safety in neonatal care.
Area of Science:
- Neonatal Medicine
- Clinical Pharmacy
- Patient Safety
Background:
- Medication errors are frequent in neonatal care, particularly with off-label drug use.
- The complexity of prescribing and administering medications to newborns increases error risk.
Observation:
- A preterm infant received paracetamol at a dose 20 times higher than prescribed.
- The infant's initial plasma paracetamol level was 480 µg/mL.
Findings:
- N-acetylcysteine was administered as an antidote.
- The infant experienced a satisfactory clinical outcome following the intervention.
Implications:
- This case underscores the vulnerability of preterm infants to medication errors.
- Implementing robust safety measures in neonatal units is crucial to prevent such incidents.
- Accurate dosing and vigilant monitoring are essential for safe medication administration in neonates.
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