Errores en la preparación de fármacos intravenosos en una Unidad de Cuidados Intensivos Neonatal. Una potencial fuente de eventos adversos

Abstract

IntroductionTo determine the rate of errors during preparation of intravenous drugs in a regional Neonatal Intensive Care Unit (NICU). MethodsA prospective observational study was performed on 24 non-consecutive working days. The vancomycin and tobramycin solutions administered were analysed to determine drug concentrations. We defined 2 types of error: 1) calculation error, when the deviation between the dose prescribed by the physician and theoretical dose administered, according to calculations performed by the nurse, was greater than ±10%, and 2) precision error, when the deviation between the theoretical concentration and that determined by the laboratory was greater than ±10%. ResultsA total of 91 samples were collected, 52 of vancomycin and 39 of tobramycin. Calculation errors were detected in 4.6% of samples. Precision errors were identified in 37.9% of the total sample. ConclusionsAlthough the errors reported did not produce adverse clinical consequences, our findings point out a potential source of severe complications. Better methods in the preparation of intravenous medications in NICU are needed.