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Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
[Medication errors in a neonatal unit: One of the main adverse events]
M T Esqué Ruiz1, M G Moretones Suñol1, J M Rodríguez Miguélez1
1Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
Insights
Over seven years, 511 medication errors (MEs) occurred in a neonatal unit, with administration errors being most common. Implementing preventive strategies is crucial for patient safety.
Area of Science:
- Neonatal care
- Patient safety
- Medication error analysis
Background:
- Neonatal units face high risks of treatment errors.
- Medication errors (MEs) are avoidable incidents causing patient harm.
- Understanding ME incidence and causes in neonatal settings is vital.
Purpose of the Study:
- To report the incidence and characteristics of medication errors in a neonatal unit.
- To identify causal factors contributing to medication errors.
- To present strategies implemented for ME prevention.
Main Methods:
- Analysis of reported medication errors within a neonatal unit.
- Data collection over a seven-year period.
- Categorization of errors by type, cause, and patient impact.
Main Results:
- 511 MEs reported over seven years; incidence of 32.2/1000 hospital days.
- Administration errors (68.1%) were most frequent; 0.6% caused permanent damage or death.
- Distraction (59%) was the primary causal factor; nurses reported 65.4% of MEs.
Conclusions:
- Determining the current state of MEs is essential for effective prevention.
- Teamwork and good practices are key to fostering a safety climate.
- Continuous monitoring and implementation of preventive measures are necessary.
Introduction:
Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented.
Material And Methods:
An analysis was performed on the ME declared in a neonatal unit.
Results:
A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed.
Conclusions:
It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.
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