Prescribing errors in a Brazilian neonatal intensive care unit.

Ana Paula Cezar Machado,Catharina Somerlate Franco Tomich,Rogério Melo Costa Pinto,Simone Franco Osme,Nilson Penha-Silva,Maria Angélica Oliveira Mendonça,Vânia Olivetti Steffen Abdallah,Daniela Marques De Lima Mota Ferreira

doi:10.1590/0102-311x00194714

Ana Paula Cezar Machado, Catharina Somerlate Franco Tomich + Show 6 more

Open Access

https://doi.org/10.1590/0102-311x00194714

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Abstract

Pediatric patients, especially those admitted to the neonatal intensive care unit (ICU), are highly vulnerable to medication errors. This study aimed to measure the prescription error rate in a university hospital neonatal ICU and to identify susceptible patients, types of errors, and the medicines involved. The variables related to medicines prescribed were compared to the Neofax prescription protocol. The study enrolled 150 newborns and analyzed 489 prescription order forms, with 1,491 medication items, corresponding to 46 drugs. Prescription error rate was 43.5%. Errors were found in dosage, intervals, diluents, and infusion time, distributed across 7 therapeutic classes. Errors were more frequent in preterm newborns. Diluent and dosing were the most frequent sources of errors. The therapeutic classes most involved in errors were antimicrobial agents and drugs that act on the nervous and cardiovascular systems.

Highlights

Especially those admitted to neonatal intensive care units (ICU), are highly vulnerable to medication errors [1,2,3]
224 neonates were admitted to the neonatal ICU
In accordance with the findings of several authors [1,3,7,8,11,13,22], this study shows that medication errors are common in a Brazilian neonatal ICU

Summary

Introduction

Especially those admitted to neonatal intensive care units (ICU), are highly vulnerable to medication errors [1,2,3]. The immaturity of organs causes difficulties for neonates, especially the very premature, to adapt to extra uterine life, because they often have multiple morbidities and need complex and intensive medical care. This exposes them to a high number of prescriptions, and a greater risk of adverse reactions 4. The repertoire of prescribed drugs in the neonatal ICU is relatively limited compared to the ICU, whether pediatric or adult, the process of prescribing, dispensing and administrating drugs is much more complex 2. Children and especially newborns have lower internal reserves compared to adults, and are less able to mitigate errors [1,2,7]

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