Voluntary Neonatal Medication Incident Reporting-A Single Centre Retrospective Analysis

Area of Science:

• Neonatal intensive care
• Medication safety
• Clinical incident reporting

Background:

• Medication errors are frequent in neonatal intensive care units (NICUs), primarily involving dosage and prescription mistakes.
• A voluntary, nonanonymous incident reporting system (RiskMan) was utilized to capture these errors.

Purpose of the Study:

• To identify common medication errors reported over a twelve-year period at an Australian tertiary NICU.
• To analyze the types and frequency of medication errors within this specific high-risk population.

Main Methods:

• A single-centre cohort study analyzed medication-related incidents reported prospectively via the RiskMan online database from 2010 to 2021.
• Incidents were categorized into administration, prescription, pharmacy-related, and other error types.

Main Results:

• A total of 583 medication errors were reported, with administration (41.3%) and prescription (24.5%) errors being most prevalent.
• Nursing and midwifery staff (77%) reported the majority of incidents. Most outcomes were minor (98%), but one extreme incident was linked to a neonate's death.

Conclusions:

• Medication errors in the NICU are a significant concern, necessitating enhanced improvement initiatives.
• Implementing evidence-based interventions in routine practice is crucial to reduce medication errors and improve neonate safety.