Medication errors in neonates admitted in intensive care unit and emergency department

Abstract

Background : Medication is the most common health-care intervention,\nand the errors arising out of its usage are potentially an avoidable\ncause of iatrogenic injuries. There are reports of medication errors\nfrom neonatal emergency setups. Aims : To study the medication errors\nof ordering, dispensing and administering in neonates admitted for\nemergency care and to compare the errors occurring in the emergency\ndepartment (ED) with those occurring in the neonatal intensive care\nunit (NICU) of a teaching hospital in north India. Primary objective:\nTo study the medication errors in ordering and dispensing for neonates.\nSecondary objective: To compare these errors in 2 different settings -\nED and NICU. Materials and Methods : We did a retrospective chart\nreview of neonatal prescriptions written in the 4 months from January\nto April 2004 in the neonatal intensive care unit and the pediatric\nemergency department. The prescriptions were analyzed from the case\nrecords bearing an even registration number, obtained from the hospital\n′medical records′ section. Medication error was defined as\n′any preventable event that occurs in the process of ordering,\ntranscribing, dispensing, administering or monitoring a drug\nirrespective of whether the injury occurred or potential for injury was\npresent.′ Results : A total of 821 prescriptions were analyzed\nand 81 (9.6%) errors were detected. The error rate was found to be 1.5\n(54/38) and 0.7 (27/38) per patient in ED and NICU, respectively, being\nhighly significant in ED. Every tenth prescription had medication error\nin ordering or dispensing; of this, every sixth prescription in ED and\nnineteenth prescription in NICU had medication error. Dosing errors\nwere the commonest form of detected errors. None of the errors caused\nany significant harm to the patient but had the potential to cause\nsevere injury, and majority of these errors were preventable. \nConclusion : Medication errors are common in neonatology; more so, in\nemergency departments than in the neonatal intensive care units.