NICU Medication Errors: Identifying a Risk Profile for Medication Errors in the Neonatal Intensive Care Unit

TA Stavroudis; AD Shore; L Morlock; RW Hicks; D Bundy; MR Miller


J Perinatol. 2010;30(7):459-468. 

In This Article

Abstract and Introduction


Objective: To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).
Study Design: A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao–Scott modified χ2 test was used for analysis.
Result: 6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P≤0.05).
Conclusion: Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.


Since the release of the Institute of Medicine reports 'To Err Is Human' and 'Crossing the Quality Chasm: A New Health System for the 21st Century,' efforts have been made to further establish centralized reporting systems to understand the factors involved in medication errors.[1–7] Medication errors are common in pediatrics and, in particular, the neonatal intensive care unit (NICU).[7,8] Errors with the potential to cause harm are eight times more likely to occur in the NICU as compared with adult settings in the hospital.[8] Moreover, medication errors comprise 47% of medical errors submitted to the Vermont Oxford Network's voluntary reporting system.[7] With a birth rate of 14.3 per 1000 persons in the United States and admission rates to NICUs as high as 6.6%, the repercussions of NICU medication errors can be considerable.[9–11]

Neonates are a particularly vulnerable population and may be at further risk of harm from medication errors because of changing body size, weight-based dosages, off-label drug usage, availability of stock solutions in a variety of concentrations, inability to communicate with providers, and changing developmental systems affecting drug absorption, distribution, metabolism, and excretion.[12–18] For example, the necessary calculations involved in the ordering of medications and in the dilution of stock drugs in the NICU place these patients at risk for harm from 10- to 100-fold dosing errors.[19] Nevertheless, the understanding of medication errors affecting the care of the neonate is in its early stages, thus hampering efforts to identify targets for intervention in preventing these errors.

Since 1995, the Institute for Safe Medication Practices (ISMP) has made efforts to identify drugs most likely to cause harm to adult patients and has termed these drugs 'High-Alert Medications.' In 2005, ISMP established an updated list of 33 drugs and drug categories considered to be high-alert medications.[20] To our knowledge, there are no reports of the risk of harm from ISMP High-Alert Medication use in neonates in the literature to date.

The objective of our study is to further expand our knowledge of medication errors that affect the care of the neonate by reviewing medication errors reported to MEDMARX with the goal of identifying a risk profile for harmful medication errors in the NICU. We hypothesize that infants in the perinatal period and NICU patients who were prescribed ISMP High-Alert Medications are more likely to have medication errors reported as having resulted in harm to the patient.


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