© 2004 Archives of Disease in Childhood Fetal and Neonatal Edition
PERSPECTIVES
Medication errors
Medication errors in the neonatal intensive care unit: special patients, unique issues
1 Department of Medicine and Quality Improvement Program, Children’s Hospital, Boston, MA 02115, USA
2 Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
Correspondence to:
Correspondence to:
Dr Gray
Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA; jgray@bidmc.harvard.edu
Accepted 19 December 2003
Medication errors are quite common in the neonatal intensive care unit
Keywords: patient safety; medication errors; intensive care; premature infants
| The first 150 words of the full text of this article appear below. |
Medical errors are a common occurrence in the neonatal intensive care unit (NICU). Although this high risk, fragile patient population is prone to a wide array of errors, medication errors are particularly common. Medication errors were the most common error type submitted to the Vermont Oxford Network’s NICQ.org voluntary reporting system.1 Kaushal and colleagues2 identified errors in 5.5% of NICU medication orders. Of note, potential adverse drug events (errors that had the potential to harm the patient but were intercepted, or potentially harmful errors that reached the patient but fortuitously did not result in injury) occurred eight times more often in NICU patients than in adults in hospital. Neonates, especially very low birthweight babies, are particularly vulnerable to adverse sequelae of medication errors as they have a limited ability to "buffer" such mistakes.
Nursing practice has long recognised the need for extreme vigilance and a structured approach to
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