Mark Andrew Castelo Gaerlan Elective 2

BSN IV Paper #7

SUMMARY:

Medication errors are a common incidence in the neonatal intensive care unit (NICU).

Kaushal and colleagues identified errors in 5.5 % of NICU medication orders. There are a lot of

factors affecting this occurrence. First, the repertoire of drugs prescribed in the NICU is

relatively limited compared with adult older populations and the process of ordering, dispensing,

and administering them is more complex in newborns since calculations are based on the infants

weight and may need to be updated as the infant gains or loses weight. Second, drugs prescribed

in the NICU are often used in an off label or unlicensed fashion resulting in a lack of

comprehensive and authoritative standards for doses. Third, dispensing drugs is also complex as

pharmacists often have to dilute stock solutions in order to provide doses that are extremely

minute compared with adult standards. Fourth, errors in the route of administration of drugs and

enteral nutrition are also common. Finally, 11% of NICU errors involved patient

misidentification. Analysis by the Center for Patient Safety in NICU care suggest that as many as

1/2 of infants in the NICU are at risk of misidentification on any given day.

REACTION:

Medication errors are among the most common health threatening mistakes that affect

patient care. It can significantly affect patient safety and treatment cost and result in hazards for

patients and their families. The main professional goal of nurses is to provide and improve

human health. We are trained to have the need for extreme vigilance & approach to prevent

medication errors. Giving medicine is probably one of the most critical duties of nurses since the

resulting errors may have unintended, serious consequences for the patient. Before medication

administration, it is imperative to check the 5 “Rights” which provides a framework for safety in

nursing. Nurses should ensure that the Right drug is given in the Right dose at the Right interval

(time) through the Right route to the Right patient.

Error prevention doesn’t involve nurses alone. It should be a multidisciplinary process

involving all healthcare personnel like doctors, pharmacists working as a team. Attention to good

prescribing practices and accurate communication are essential. Good communication and

teamwork requires a blame free environment and a culture that places a high value on patient

safety and optimum restoration of health.

REFERENCE:

Medication errors in the neonatal intensive care unit: special patients, unique issues J E Gray 2 , D A Goldmann 1 , 19 December 2009