Related Experiment Video
Updated: Aug 10, 2026
Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
Medication safety in neonatal care: a review of medication errors among neonates
Natalia Krzyzaniak1, Beata Bajorek2
1University of Technology, Sydney, Graduate School of Health (Pharmacy), PO Box 123, Broadway, NSW 2007, Australia.
Insights
Hospital medication errors are common across all ages, with neonates experiencing unique overdosing risks. Integrating clinical pharmacists can help mitigate these medication errors.
Area of Science:
- Medical Safety
- Pharmacology
- Patient Care
Background:
- Medication errors represent a significant patient safety concern in hospitalized individuals.
- Understanding error patterns across different age groups, from neonates to the elderly, is crucial for targeted interventions.
Purpose of the Study:
- To delineate medication errors in hospitalized patients.
- To compare medication errors in neonates with those occurring across the entire age spectrum.
Main Methods:
- A comprehensive literature search was conducted across PubMed, Embase, and Google Scholar.
- Searches focused on identifying medication errors in pediatric, adult, elderly, and neonatal hospitalized populations.
Main Results:
- Fifty-eight articles were reviewed, confirming medication errors in all patient groups.
- Prescribing and administration errors, particularly dosing errors, were most frequent.
- Neonates showed high rates of overdosing and misidentification errors; elderly patients had unique issues like therapy duplication.
- Commonly implicated medications included heparin, antibiotics, insulin, morphine, and parenteral nutrition.
Conclusions:
- All stages of medication use are vulnerable to errors across patient age groups.
- Developing targeted strategies for specific populations, including integrating pharmacy services, is essential for improving medication safety.
Objective:
The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum.
Method:
In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients.
Results:
A total of 58 articles were reviewed. Medication errors were well documented in each patient group. Overall, prescribing and administration errors were most commonly identified across each population, and mostly related to errors in dosing. Errors due to patient misidentification and overdosing were particularly prevalent in neonates, with 47% of administration errors involving at least tenfold overdoses. Unique errors were identified in elderly patients, comprising duplication of therapy and unnecessary prescribing of medicines. Overall, the medicines most frequently identified with error across each patient group included: heparin, antibiotics, insulin, morphine and parenteral nutrition. While neonatal patients experience the same types of medication errors as other hospitalized patients, the medication-use process within this group is more complex and has greater consequences resulting from error. Suggested strategies to help overcome medication error most commonly involved the integration of a clinical pharmacist into the treating team.
Conclusion:
This review highlights that each step of the medication-use process is prone to error across the age spectrum. Further research is required to develop targeted strategies relevant to specific patient groups that integrate key pharmacy services into wards.
Related Concept Videos
01:29Drug Dosing: Infants and Children
01:23Pharmacokinetics in Pediatric Patients: Overview and Drug Absorption
01:17Pharmacokinetics in Pediatric Patients: Drug Distribution
01:26Pharmacokinetics in Pediatric Patients: Drug Excretion
01:24Drug Toxicity: Risk factors
01:26Pharmaceutical Poisoning: Potential Scenarios