Medication Errors in Newborn Intensive Care Unit
Medication errors can occur quite often in the neonatal care units, as in any other department. However, given the specifics of these departments and the vulnerability of young patients, such errors have much greater potential harm. Therefore, the topic of medical errors in the NICU deserves special attention and study. Reporting medical errors contributes to a better understanding of the time, place, and types of such errors. The PICO question related to the topic is: “For neonates in the NICU, does the use of proper medication administration reduce the future risk of medication errors compared with the improper use of medication administration?” This paper presents the evidence table observing the studies regarding the medication errors in the NICU that discover the medication threat neonates face in the NICU environment. The paper also includes the analysis of the literature discussed and recommendations on how to overcome the stated problem.
|Author/ Year||Purpose||Design & Methods||Sample/Setting||Results|
|Alghamdi et al. (2019)||To analyze the existing studies on the incidence and nature of errors involving medicine and adverse drug events which could be prevented in neonatal and pediatric intensive care units.||Systemic review; quantitative. The search covered seven electronic databases in the period between January 2000 and March 2019. The research focused on quantitative studies which concerned preventable adverse drug events and medication errors and utilized medication chart review, direct observation, or a set of methods.||Setting: Pediatric intensive care units, neonatal intensive care units. |
Sample: Thirty-five studies were chosen for inclusion. The sample included children younger than 18 years old and admitted to neonatal or pediatric intensive care units.
|Research shows that the pediatric intensive care units had a median rate of medication errors of 14.6 per 100 medication orders, which was between 6.4 and 9.1 per 1000 patient days. The medication error rates of the neonatal intensive care units analyzed in the study varied between 4 and 35.1 per 1000 patient-days and from 5.5 to 77.9 for 100 medication prescriptions. Medication ordering and administration were the processes with the highest incidence of errors in both settings, and dosing errors were the most common ones.|
|Ceriani Cernadas M. J., et al. (2019)||To review available reports on medication errors in children who were hospitalized to analyze their causes, frequency, and adverse events (AEs).||Observational; a prospective study. Prospective study of medication dispensing errors conducted at Pediatric Intensive Care Unit (PICU), Pediatric Clinic (PC), and Neonatal Intensive Care Unit (NICU).||Setting: NICU, PC, and PICU. |
Sample: Children who were hospitalized in NICU, PC, and PICU.
|The rate of medication errors discovered in hospitalized children was 41%. The most common error concerned dosing were. Out of 91 AEs which were reported, 58 % were mild, and 58% took place was in NICU.|
|Cooley-Tubbs, H. L., et al. (2019)||To evaluate the association of NICU nurse workload with missed nursing care.||Quantitative; a prospective study. |
The study analyzes the association between missed nursing care and nurse shift-level workloads in a neonatal intensive care unit based on data reported by nurses.
|Setting: At a 52-bed NICU in Midwestern Academic Medical Center between March 1, 2013, and January 31, 2014. |
Sample: Registered nurses who completed unit orientation and delivered direct patient care.
|When analyzing every workload variable together, 4 of 12 models showed a link of odds of missed care with staffing ratios, while the relationship with NASA-TLX ratings was considerable in each model. Acuity scores associations observed as part of the study were few.|
|Duarte SCM., et al. (2021)||To establish the incidence of DRPs in the patients in NICU and to sort DRPs according to cause, type, and pharmaceutical conduct.||Quantitative-qualitative; descriptive study. |
This study was done in the neonatal Intensive Care Unit. Participants: 22 nursing professionals. Data collection was performed through interviews and sent to the thematic analysis.
|Setting: NICU in a hospital in Brazil in the period between January 2014 and November 2016. |
Sample: The data gathered from the clinical pharmacy service. The data on an overall of six hundred individuals (neonates) were analyzed during the research.
|Sub-optimal effect and inappropriate dose selection were the most frequent problem and cause with a prevalence of 52.8% and 39.75%, respectively. More than 30% of all children experienced DRP of a substantial safety relevance. The majority of the pharmaceutical interventions involved drug prescription, with more than 90% acceptance by attending physicians.|
|Godshall, M., et al. (2018)||This article discusses why medication errors still occur at alarming rates despite automated medication delivery systems and bar code technology designed to prevent them.||Qualitative and quantitative. |
Mixed study research methods were applied.
|Settingandsample: Fifty-one nurses from seven hospitals in Pennsylvania answered an informal paper questionnaire on automated dispensing systems and barcoding.||When asked if they have been personally involved in a medication error, 12 nurses answered that they had been involved in a medication error involving bar code technology. Out of all the nurses surveyed, only one nurse had witnessed the death of a patient due to an issue with the ADS. The survey also found that workarounds are alarmingly common: all nurses said they overrode at least one warning per shift.|
|Labib, J. R., et al. (2017)||To evaluate the association of NICU nurse workload with missed nursing care.||Descriptive cross-sectional study. |
The study method was a self-administered questionnaire that nurses anonymously took.
|Setting: This study was conducted in a NICU at Cairo University Pediatric Hospital (CUPH) in Egypt. The study took place over a three-month period that started in January 2017. |
Sample: Reports on missed nursing care and shift-level workload were competed by 136 nurses.
|The reports made by 136 nurses concerned 418 infants over the span of 332 shifts, each lasting 12 hours. Once workload variables were independently modeled, 7 of 12 models showed a considerable worsening association of odds of missed care with increased infant-to-nurse ratio, and every model indicated a substantial worsening association of odds of missed care with increased NASA-TLX subjective workload ratings.|
|Leopoldino, R. D., et al. (2019)||The purpose of this study was to determine the incidence of DRPs in NICU patients and to characterize DRPs according to type, cause, and corresponding pharmaceutical conduct.||Quantitative, prospective, observational. |
A study was conducted in a teaching hospital’s NICU. The Pharmaceutical Care Network Europe was used to classify DRPs, which were then evaluated according to relevance-safety.
|Setting: A hospital in Brazil in the period starting from January 2014 until November 2016. The data were gathered from the clinical pharmacy service, and it did not include neonates who were admitted for less than 24 hours. |
Sample: The research studied six hundred neonates, who had a mean birth weight of 1779 ± 885 g and a mean gestational age of 31.9 ± 4.1 weeks.
|6.8% patient-days was the incidence of DRPs in the NICU, which affected 59.8% of neonates. Sub-optimal effect (52.8%) and inappropriate dose selection (39.75%) were the most frequent issue and cause. The medication type the most often involved in DRPs was anti-infective. More than one-third of neonates were exposed to DRP of significant or high safety relevance. Most of the pharmaceutical interventions were related to drug prescription, with over 90% acceptance by attending physicians.|
|Quinton-Shapcott, S., et al. (2020)||This article describes a quality improvement initiative to decrease maternal and newborn separation and to reduce drug errors by stopping the ‘baby train’ of well infants attending the neonatal unit for administration of empirical intravenous antibiotics (IVABs).||Quantitative. |
A time in motion study was performed of the infants’ journey while on a course of IVABs. This offered tangible quantitative data to highlight the issues around maternal and newborn separation.
|Setting: Colchester Hospital NNU is a level two local NNU. |
Sample: 3,700 births, 464 admissions to NNU, and 260 infants treated for suspected sepsis; an average of three infants per day.
|Workload concerns were raised with both maternity and neonatal nurse teams commenting on how they initially felt it had increased their workload, although they understood the importance of not separating mother and baby. Feedback was collected anonymously from staff by way of semi-structured surveys.|
|Rocha et al. (2018)||To study Nursing care related to the safe use of medication in the setting of Neonatology and Pediatrics.||A qualitative, descriptive, and exploratory study. |
For this research study, the data was collected through semi-structured interviews by 23 workers/participants of the nursing teams. They subjected them to the technique of Content Analysis in the Thematic Analysis modality.
|Setting: Neonatology and |
Sample: 23 workers of the Nursing teams.
|Results referred to the supervision by the Nursing staff, the registration of the medication administered in a care plan, the millimetric calculation of doses, checking the validity of the medication, non-application of chemically incompatible drugs at the same time, ensuring the asepsis of the administration site, taking care of the temperature appropriate for storage, use of medicines and doubts before the administration of the drugs.|
Background / Problem
Patients who are admitted to intensive care units are much more vulnerable to medical errors, including errors associated with prescribing the correct doses and names of drugs. At the same time, scientists note that patients in pediatric intensive care units are seven times more likely to face the listed errors (Alghamdi et al., 2019). The National Institute for Care Excellence suggests that “when deciding on the appropriate care setting for a baby, take into account the baby’s clinical needs and the competencies necessary to ensure safe and effective care” (Quinton-Shapcott & Knights, p. 197).
The PICO question is: “For neonates in the NICU, does the use of proper medication administration reduce the future risk of medication errors compared with the improper use of medication administration?” The population is neonates in the NICU, the intervention is proper medication administration, the issue of control is not ensuring proper medication administration, and the desired outcome is reduced medication errors. The purpose of the literature review was to study the types and circumstances of the medication errors in NICU to prevent future errors.
The univariate search method was used to find and analyze the literature, and the CINHAL and Cochrane Library databases were used to gather the proper articles. The search terms used were medication errors, medication drugs prescription, proper dosages, NICU, neonates, intensive care, PICU. The initially located number of articles was 40 articles, of which 22 articles were reviewed, and this number was then reduced to 9 articles that met the research expectations. Noteworthy, only scholarly, peer-reviewed journals were considered, and only those that met the criteria of inclusion for the project. These were the criteria of limitation – no more than five years, compliance with the topic and more narrowly defined topic of medical errors in NICU, and publication in official medical journals. At the same time, the exclusion criteria for the project were the absence of specific data and the use of qualitative research methods without an evidence base confirming the reliability of the collected data.
Out of nine studies analyzed, three studies were descriptive and qualitative, five studies were quantitative, three studies were prospective, and two studies used both qualitative and quantitative methods. The research samples were mostly neonates and their mothers, as well as nurses and medical personnel prescribing the medications in the NICU settings.
In most researches, the data prove the connection between medication errors and neonates’ health risks and recovery time. Moreover, a greater number of medication errors that are not recorded and not evaluated is associated with a subsequent increase in such errors. Overall, high levels of errors were reported by nurses, with issues concerning administration and ordering being the most common, while the errors concerning dosing were most often reported. In some NICUs, the medication error rate reached 41%, which speaks of the urgent necessity of adequate measures. One more popular error was inappropriate dose selection, which led to a sub-optimal effect. Bar code technologies were also common causes for the medication errors, and many nurses reported the workarounds that distracted them from patients ’requests and caused the missed care events. Another issue that should be addressed was the workload concerns since the nurses had to attend to both neonates and their mothers and felt the doubled responsibility for not separating mother and baby.
Given the information presented above, the recommendations following should be applied to change the situation. Firstly, it is necessary by any means to reduce the number and frequency of medication errors since there is an excessive number of them in all ICUs, including NICUs, which can be called a general negative trend requiring immediate solutions. Then, particular attention should be paid to the errors involving prescription and administration of medication, as well as inappropriate dose selections. At the same time, the nurses should solve the bar code-related problem and be more attentive to the bar codes. Finally, the hospital management should consider the problems related to workarounds, supposedly by improving the staffing ratios. Workload concerns in mother and baby units should be addressed as well. The listed recommendations should be implemented to reduce the potential threats and dangers faced by the neonates and bring some clarity and order in the working processes with the critical amounts of patients.
The paper presents the report and analysis of evidence regarding the errors involving medication which took place in neonatal intensive care units in various settings worldwide. The population studied is nurses who work with neonates, and the problem discussed is the errors concerning medication occurring in NICUs. The literature review results showed there is a constantly increasing number of errors related to medication, especially those concerning administration and prescription, which is an overall general tendency in NICUs around the world. Moreover, there is a problem of workarounds and overloads related to providing care for mother and baby wards. The specific recommendations were stated to be implemented by nurses and managers in hospital settings.
Alghamdi, A. A., Keers, R. N., Sutherland, A., & Ashcroft, D. M. (2019). Prevalence and nature of medication errors and preventable adverse drug events in Pediatric and neonatal intensive care settings: a systematic review. Drug Safety, 42(12), 1423-1436.
Cernadas, J. M. C., Bogado, L., & Galletti, M. F. (2019). Voluntary and anonymous reporting of medication errors in patients admitted to the Department of Pediatrics. Archivos Argentinos de Pediatria, 117(6), e592-e597.
Duarte, S. D. C. M., Azevedo, S. S. D., Muinck, G. D. C. D., Costa, T. F. D., Cardoso, M. M. V. N., & Moraes, J. R. M. M. D. (2020). Best Safety Practices in nursing care in Neonatal Intensive Therapy. Revista Brasileira de Enfermagem, 73.
Godshall, M., & Riehl, M. (2018). Preventing medication errors in the information age. Nursing2020, 48(9), 56-58.
Labib, J. R., Youssef, M. R. L., & Abd El Fatah, S. A. (2018). High alert medications administration errors in neonatal intensive care unit: A pediatric tertiary hospital experience. Turkish Journal of Pediatrics, 60(3).
Leopoldino, R. D., Santos, M. T., Costa, T. X., Martins, R. R., & Oliveira, A. G. (2019). Drug-related problems in the neonatal intensive care unit: Incidence, characterization and clinical relevance. BMC Pediatrics, 19(1), 1-7.
Martins da Rocha, C., Calcagno Gomes, G., Portella Ribeiro, J., Capa Verde Almeida de Mello, M., Netto de Oliveira, A. M., & Batista da Silva Maciel, J. (2018). Safe administration of medication in neonatology and pediatrics: Nursing care. Journal of Nursing UFPE/Revista de Enfermagem UFPE, 12(12).
Quinton-Shapcott, S., & Knights, S. (2020). Waving goodbye to the baby train: reducing mother-infant separation and drug errors by collaborative working. Infant, 16(5).
Tubbs-Cooley, H. L., Mara, C. A., Carle, A. C., Mark, B. A., & Pickler, R. H. (2019). Association of nurse workload with missed nursing care in the neonatal intensive care unit. JAMA Pediatrics, 173(1), 44-51.