Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity

Area of Science:

• Neonatal Medicine
• Pediatric Patient Safety
• Clinical Pharmacy

Background:

• Medication errors pose a significant risk to vulnerable patient populations.
• Neonatal intensive care units (NICUs) require meticulous medication administration protocols.

Purpose of the Study:

• To identify and analyze the causes of medication errors and incidents in a level 3 NICU.
• To determine the incidence rate of medication errors per patient day.

Main Methods:

• Prospective examination of medication errors and incidents over a 2-year period.
• Data collection on incident types, causes, and severity.
• Calculation of incident rates per 1000 patient days.

Main Results:

• A total of 313 incidents were recorded over 23,307 patient days (13.4 incidents per 1000 patient days).
• The most frequent causes were missed medication doses (n=52) and intravenous infusion regulation issues (n=32).
• Errors in physician orders led to serious incidents in 20% of cases, compared to 6% for other causes.

Conclusions:

• Medication administration errors and IV infusion management are critical areas for intervention in NICUs.
• Physician order errors represent a high-risk category requiring targeted safety measures.
• Reducing medication errors is essential for improving neonatal patient safety outcomes.