Medication errors in the neonatal intensive care unit: special patients, unique issues.

M edical 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. Kaushal and colleagues 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 preventingmedication 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. 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. Nowhere in the hospital is the challenge greater than in the NICU. The repertoire of drugs prescribed in the NICU is relatively limited compared with adult and older paediatric populations, but the process of ordering, dispensing, and administering them is more complex in newborns. The process for ordering drugs in the NICU is uniquely complex; more than three quarters of medication errors occurred during this stage. As doses are calculated according to the infant’s weight, virtually all prescriptions require patient specific calculations and may need to be updated as the infant gains or loses weight. Weight and gestational age are not the only factors that need to be considered. For premature infants, doses must also be modified on the basis of the developmental maturity of specific metabolic and excretory pathways. Drugs prescribed in the NICU are often used in an off label or unlicensed fashion. As a result, no comprehensive and authoritative standards for doses exist. Therefore clinicians are often confronted by a dizzying array of published reference standards for a single drug. Recommendations are surprisingly variable even for drugs that have been studied in neonates and approved for use by the Food and Drug Administration. For example, widely used references in the United States suggest total daily ampicillin doses that vary by a factor of 3–4 for the same 1 kg patient. Certainly, for a drug with a wide therapeutic index, this difference may not be clinically significant. However, the lack of a single dosing standard within a hospital can complicate the development of error reduction strategies in which doctors, nurses, and pharmacists verify doses. NICU drug dispensing is also complex. Pharmacists often have to dilute stock solutions in order to provide doses that are extremely minute compared with adult standards. In this issue of the journal, Chappell and Newman document the potential for 10–100-fold dosing errors associated with the use of stock drug concentrations intended primarily for use in adults. Of particular concern is the fact that three of 10 drugs at risk of 10-fold dosing errors and all four at risk of 100-fold errors are high alert drugs as defined by the Institute for Safe Medication Practice. Even more alarming is the fact that these decimal point errors represent only a portion of the calculation errors that can complicate the ordering and preparation process. Errors in the route of administration of drugs and enteral nutrition are also common, complicated 13.3% of potentially harmful medication errors seen in two NICUs in the United States. In another report, Suresh and colleagues noted potentially very serious administration errors, such as infants fed expressed breast milk intravenously. Unlike adult care units, enteral feeding tubes and intravenous lines are often of the same calibre and appearance and have hubs of similar size. This type of error could be prevented by adopting administration systems with ‘‘forcing functions’’ that prevent feeding pumps and syringes from being attached to intravenous lines. Regrettably, these systems are not in widespread use in NICUs, in part because of incompatibilities with existing equipment and work flow processes. Finally, patientmisidentification occurs commonly in the NICU. One quarter of the serious medication errors reported in this issue by Simpson et al involved patient misidentification. Similarly, Suresh et al found that 11% of NICU errors involved misidentification. The increasing incidence of multiple gestations with premature births is in part responsible for these errors, but suboptimal systems for identifying babies contribute to the problem. Analyses by the Center for Patient Safety in NICU care suggest that as many as one half of infants in the NICU are at risk of misidentification on any given day (unpublished work). The patient safety movement has highlighted numerous approaches to preventing medication errors, but which interventions have the potential to have the greatest impact? Fortescue and colleagues have identified three interventions with the largest potential to decrease NICU medication errors: ward based clinical pharmacists, computerised physician order entry (CPOE), and improved communication among NICU clinicians. The involvement of clinical pharmacists in intensive care unit rounds significantly reduces dosing and other types of error in adult care. In this issue, Simpson et al conclude that similar improvements can be achieved through the input of an NICU based clinical pharmacist. Although their data are encouraging, confidence in their F472 PERSPECTIVES