Prescription errors in a neonatal intensive care unit from Buenos Aires

• Published in: Revista de la Facultad de Ciencias Medicas (Cordoba, Argentina) Vol. 69; no. 1; p. 15
• Main Authors: Serra, Vera Vanina, Pena, Fabiana, Ossorio, Maria Fabiana, Pedicone, Carlos, Armadans, Marcelo
• Format: Journal Article
• Language: Spanish
• Published: Argentina 01.03.2012
• Subjects: Analgesics, Opioid - therapeutic use; Anti-Bacterial Agents - therapeutic use; Argentina; Cardiotonic Agents - therapeutic use; Humans; Infant, Newborn; Intensive Care Units, Neonatal - statistics & numerical data; Medication Errors - classification; Medication Errors - statistics & numerical data; Retrospective Studies; Argentina

Although error could be present in almost every medical practice, they are more frequent and potentially more dangerous in neonatal intensive care units (NICU). To determine prescription error rate of intravenous drugs in a Neonatal Intensive Care Unit (NICU), and to describe type of error (dose, dilution, and interval) and medication (antibiotics, inotropics, or analgesics). Observational study including medical records of patients hospitalized in a NICU, receiving any of the above mentioned drugs. Each prescription was compared with one provided by a specific software. Prescription error was defined as >10% of difference between both values. 362 prescriptions from 82 patients were analyzed. An error was observed in 42.5% (95%CI 37.4 - 47.8) of all prescriptions, including 148 (96.1%; 95%CI: 91.3-98.4) antibiotics prescriptions, 5 (3.2%; 95%CI: 1.2-7.7) inotropics prescriptions and 1 (0.7%; 95%CI: 0.01-4.2) analgesics prescriptions. Prescription errors were due to frequency error in 53.8% 95%CI: 45.6-61.8 of cases and to volume error in 46.1% (95%CI: 38.1-54.3). Almost half of the intravenous drugs prescriptions included an error, being more frequently related to interval, followed by dosing; no errors in dilution were detected. Using prescription software could improve patient's safety.