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Medication errors in the neonatal intensive care unit: special patients, unique issues
  1. J E Gray2,
  2. D A Goldmann1
  1. 1Department of Medicine and Quality Improvement Program, Children’s Hospital, Boston, MA 02115, USA
  2. 2Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA
  1. Correspondence to:
    Dr Gray
    Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA;

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Medication errors are quite common in the neonatal intensive care unit

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 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 preventing medication errors. The five “Rights” provide a framework for improving medication safety in nursing. These basic principles of standard operating procedure try to address all of the steps in the medication process: ordering, dispensing, administering, and monitoring drugs. Nurses attempt to ensure that the Right drug is given in the Right dose at the Right interval via the Right route to the Right patient.

Although nurses focus on providing error-free care, research into human factors teaches us that dedication, training, and vigilance are not enough to prevent errors in complex systems.3,4 Error prevention must be a multidisciplinary process, involving doctors, pharmacists, and nurses working as a team. The team must be backed up by robust healthcare delivery systems operating in a “culture of safety”, providing staff with a working environment that provides safeguards against human fallibility. …

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