The problem with gentamicin: reducing administration and prescribing errors in neonates treated for early onset...

We describe a quality improvement (QI) project to reduce the number of administration and prescribing errors with gentamicin on a local neonatal unit in a district general hospital, from January 2017 to August 2019. Baseline data collected showed seven errors in the first 16 months of the project (from 1999 doses). The aim of this QI project was to have no low-level, moderate-level or severe level harm errors in the intervention period. A number of interventions were carried out including a change to local guidelines and teaching sessions for staff. All Datix reports for gentamicin were reviewed as well as data collected from the pharmacy team for a further 16 months. One low harm error was reported in this period (from 1938 doses). Education of the medical and nursing staff has been a key intervention in reducing our gentamicin errors as well as changing the way we prescribe gentamicin.