Prescribing errors in a Brazilian neonatal intensive care unit

Area of Science:

• Neonatal pharmacology
• Pediatric medication safety
• Healthcare quality improvement

Background:

• Neonatal intensive care units (ICUs) present unique challenges for medication administration.
• Pediatric patients, particularly neonates, are at high risk for medication errors.
• Establishing accurate prescription practices is crucial for infant safety.

Purpose of the Study:

• To quantify the prescription error rate in a university hospital's neonatal ICU.
• To identify patient populations, error types, and specific medications associated with prescription errors.
• To compare prescribed medication variables against the Neofax prescription protocol.

Main Methods:

• Analysis of 489 prescription order forms and 1,491 medication items for 150 enrolled newborns.
• Comparison of prescribed medication variables with the Neofax prescription protocol.
• Categorization of errors by type (dosage, interval, diluent, infusion time) and therapeutic class.

Main Results:

• A significant prescription error rate of 43.5% was identified.
• Errors were most frequent in preterm newborns.
• Diluent and dosing errors were most common, affecting antimicrobial agents and drugs acting on the nervous and cardiovascular systems.

Conclusions:

• High rates of prescription errors necessitate improved medication safety protocols in neonatal ICUs.
• Targeted interventions focusing on diluents, dosing, and specific drug classes are needed.
• Continuous monitoring and adherence to established protocols like Neofax are essential for reducing neonatal medication errors.