Arch Dis Child Fetal Neonatal Ed 97:F449-F455 doi:10.1136/fetalneonatal-2011-300989
  • Original articles

The effect of a multifaceted educational intervention on medication preparation and administration errors in neonatal intensive care

  1. Katja Taxis4
  1. 1Department of Clinical Pharmacy, Isala Clinics, Zwolle, The Netherlands
  2. 2Princess Amalia Department of Pediatrics, Isala Clinics, Zwolle, The Netherlands
  3. 3Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
  4. 4Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen, The Netherlands
  1. Correspondence to Katja Taxis, Department of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Ant Deusinglaan 1, 9713AV Groningen, The Netherlands; k.taxis{at}
  1. Contributors KT and IC conceived and designed the study and drafted the article. Analysis of data and interpretation of data were carried out by KT, IC and EvdH. HM and WH were involved in the design of the study, interpretation of the data. HM, WH and EvdH were all involved in the revision of important intellectual content of the article. All authors have approved the final version of the manuscript to be published. KT acts as the guarantor of the study.

  • Received 6 September 2011
  • Accepted 10 February 2012
  • Published Online First 5 April 2012


Objective To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU).

Design Prospective study with a preintervention and postintervention measurement using direct observation.

Setting NICU in a tertiary hospital in the Netherlands.

Intervention A multifaceted educational intervention including teaching and self-study.

Main outcome measures The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts.

Results The incidence of errors decreased from 49% (43–54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25–36%). Preintervention, 0.3% (0–2%) medications contained severe errors, 26% (21–31%) moderate and 23% (18–28%) minor errors; postintervention, none 0% (0–2%) was severe, 23% (18–28%) moderate and 8% (5–12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29–0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)).

Conclusions The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.


  • Funding This study was partly funded by the Netherlands association of hospital pharmacists (NVZA). The sponsor did not have a role in the study design; in the collection, analysis and interpretation data; in the writing of the report; and in the decision to submit the paper for publication.

  • Competing interests KT received funding from Astra Zeneca for a project unrelated to this work. KT also received speaker's fees from Hospira and BBraun.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement We could provide access to the primary data.

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