Patient Safety and Quality

Certain factors increase risk of medication errors in the neonatal intensive care unit (NICU)

Babies in neonatal intensive care units (NICUs), like patients in other critical care environments, are at increased risk for medication errors. In fact, these errors are eight times more likely to take place in the NICU than an adult setting in the hospital. Given their small size, infants in the NICU are particularly vulnerable to the consequences of medication errors. A new study profiled risk factors for medication errors in the NICU. It found that human factors were behind most medication errors in the NICU, with half of them the result of mistakes during the drug administration phase.

The researchers looked at 6,749 NICU medication-error reports from 163 health care facilities. All were reported to MEDMARX, an independent Internet-based error-reporting system, between 1999 and 2005. The majority of medication errors, (3,725) were errors that reached the patient but did not cause harm. Another 1,529 errors took place but never actually reached the patient. Overall, 72 percent of errors that reached the patient did not result in harm. Four percent of actual errors resulted in permanent harm or death.

Nearly half (48.2 percent) of all reported medication errors occurred during the drug administering phase, followed by drug transcribing/documenting, prescribing, and dispensing. Over a quarter (26.9 percent) of all error types cited involved improper dose or quantity. Other types included omission errors (18.6 percent) and wrong timing (17.6 percent). Human factors were the cause of 68.4 percent of all errors, followed by miscommunication (14.4 percent). Risk factors associated with medication errors included the use of what are called high-alert medications, problems during the prescribing phase, and equipment/delivery device failures. The study was supported in part by the Agency for Healthcare Research and Quality (HS16774).

See "NICU medication errors: Identifying a risk profile for medication errors in the neonatal intensive care unit," by Theodora A. Stavroudis, M.D., Andrew D. Shore, Ph.D., Laura Morlock, Ph.D., and others in the Journal of Perinatology 30, pp. 459-468, 2010.

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