Introduction Medication errors are the commonest critical incidents in neonatal care. NPSA report frequent errors with gentamicin prescription, administration and monitoring. We developed a pathway to promote the safe use of gentamicin in our unit.

Aim The aim of the project was to compare standards of prescription, administration and monitoring of gentamicin before and after implementation of the pathway. Standards were derived from national NPSA recommendations and local guidelines.

Methodology We studied two time periods, before and after the introduction of the pathway. The dosing regimen was similar during both periods. Data was obtained from the electronic patient data management system, the drug prescription chart (pre-pathway) or the dedicated pathway documentation (post-pathway).

Results 53 cases (pre-pathway) and 56 cases (post-pathway) were analysed. There were 418 doses of gentamicin administered over the two time periods. Median gestation and birth weight was lower in pre-pathway infants compared to those in post-pathway (30 vs 31 weeks, p=0.04; 1.24 vs 1.51 kg, p=0.04).

Conclusion The introduction of a dedicated antibiotic pathway enhanced practice around gentamicin therapy with fewer delays in antibiotic administration, improved documentation and better practice around monitoring of gentamicin levels.