Newborn and Infant Nursing Reviews
Volume 8, Issue 2 , Pages 72-82 , June 2008

What Nurses Can Do Right Now to Reduce Medication Errors in the Neonatal Intensive Care Unit

  • Robin Clifton-Koeppel, MS, RNC, CNS, CPNP

      Affiliations

    • Corresponding Author InformationAddress correspondence to Robin Clifton-Koeppel MS, RNC, CNS, CPNP, UC Irvine Medical Center, 101 The City Drive, Route 162, Orange, CA 92868.

References 

  1. Barker K, Flnn E, Pepper G, et al. Medication errors observed in 36 health care facilities. Arch Intern Med. 2002;162:1897–1903
  2. Ligi I, Arnaud F, Jouve E, et al. Iatrogenic events in admitted neonates: a prospective cohort study. Lancet. 2008;371:404–410
  3. Frey B, Kehrer B, Losa M, et al. Comprehensive critical incident monitoring in a neonatal-pediatric intensive care unit: experience with the system approach. Intensive Care Medicine. 2000;26:69–74
  4. Sharek P, Horbar J, Mason W, et al. Adverse events in the neonatal intensive care unit: Development, testing and findings of an NICU-focused trigger tool to identify harm in North American NICU's. Pediatrics. 2006;118:1332–1340
  5. Ross L, Wallace J, Paton J. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83:492–497
  6. Ceci A, Felisi M, Catapano M. Medicines for children licensed by the European Agency for the evaluation of medicinal products. Eur J Clin Pharmacol. 2002;58:495–500
  7. Chappell K, Newman C. Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal neonata Ed. 2004;89:
  8. Simpson J, Lynch R, Grant J, et al. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2004;89:F480–F482
  9. Vincer J, Murray J, Yuill A, et al. Drug error and incidents in a neonatal intensive care unit: A quality assurance activity. Am J Dis Child. 1989;143:737–740
  10. Parshuram C, To T, Seto W. Systematic evaluation of errors occurring during the preparation of intravenous medications. CMAJ. 2008;178:42–48
  11. Pedersen C, Schneider P, Scheckelhoff D. ASHP national survey of pharmacy practice in hospital settings: dispensing and administration—2005. Am J health Syst Pharm. 2006;63:327–345
  12. Suresh G, Horbar J, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004;113:1609–1618
  13. Flynn E, Barker K, Pepper G. Comparison of methods for detecting medication errors in 36 hospital and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59:436–446
  14. Kohn L, Corrigan J, Donaldson M. To err is human: Building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy of Press; 1999;
  15. Bates D, Leape L, Petrycki S. Incidence and preventability of adverse drug events in hospitalized adults. J Gen intern Med. 1993;8:289–295
  16. Bates D, Cullen D, Laird N, et al. Incidence of adverse drug events and potential adverse drug events: implications for prevention. JAMA. 1995;274:29–34
  17. Leape L, Bates D, Cullen D, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35–43
  18. Classen D, Pestotnik S, Evans R, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301–306
  19. Lazarou J, Pomeranz B, Corey P. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. JAMA. 1998;279:1200–1205
  20. Kaushal R, Bates D, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114–2120
  21. Fortescue E, Kaushal R, Landrigan C, et al. Prioritizing strategies for preventing medication errors and adverse drug events in pediatric inpatients. Pediatrics. 2003;111:722–729
  22. Chuo J, Lambert G, Hicks R. Intralipid medication errors in the neonatal intensive care unit. Jt Comm J Qual Saf. 2007;33:104–111
  23. Anderson B, Ellis J. Common errors of drug administration in infants: causes and avoidance. Paediatric Drugs. 1999;1:93–107
  24. Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration of drug doses: a neglected iatrogenic diseases in pediatrics. Pediatrics. 1986;77:848–849
  25. Institute for Safe Medication Practices . Infant's death reinforces need for medications dispensed in ready-to-use form. ISMP Safety Alert. Horsham, PA: Institute for Safe Medication Practice. 1998;
  26. Rowe C, Koren T, Koren G. Errors by pediatric residents in calculating drug doses. Arch Dis Child. 1998;79:56–58
  27. Taylor J, Loan L, Kamara J, et al. Medication administration variances before and after implementation of computerized physician order entry in a neonatal intensive care unit. Pediatrics. 2008;121:123–128
  28. Balas M, Scott L, Rogers A. The prevalence and nature of errors and near errors reported by hospital staff nurses. Applied Nursing Research. 2004;17:224–230
  29. Edwards W. Patient safety in the neonatal intensive care unit. Clin Perinatology. 2005;32:97–106
  30. Leape L. Reporting adverse events. N Engl J Med. 1992;347:1633–1638
  31. Lehmann D, Page N, Kirschman K, et al. Every error a treasure: improving medication use with a nonpunitive reporting system. Jt Comm J Qual Saf. 2007;33:401–407
  32. Mayo A, Duncan D. Nurse perceptions of medication errors: what we need to know for patient safety. J Nurs Care Qual. 2004;19:209–217
  33. Frey B, Buettiker V, Hug M, et al. Does critical incident reporting contribute to medication error prevention?. Eur J Pediatri. 2002;161:594–599
  34. Institute for Safe Medication Practices . Another heparin error: Learning from mistakes so we don't repeat them. Horsham, PA:Institute for Safe Medication Practices; 2007;Available at: http://www.ismp.org/Newsletters/acutecare/articles/20071129.asp[Retrieved November 29, 2006]
  35. Hiscock M, Caroselli J, Wood S. Concurrent counting and typing: lateralized interference depends on a difference between the hands in moor skill. Cortex. 2006;42:38–47
  36. Dingus T, Klauer S, Neale , et al. The 100-car naturalists driving study, Phase II: Results of th 100-car field study. National Highway Traffic Safety Administration, report # DOT HS 810 593, April 2006; April 2006;
  37. Wiegmann D, ElBardissi A, Dearani J. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142:658–665
  38. Alvarez G, Coiera E. Interruptive communication pattern in the intensive care unit ward round. Int J Med Inform. 2005;74:791–796
  39. Ebright P, Patterson E1, Chalko B, et al. Understanding the complexity of registered nurse work in acute care settings. J Nurs Adm. 2003;33:630–638
  40. Pape T. Applying airline safety practice to medication administration. Med Surg Nursing. 2003;12:77–93
  41. Aspden P, Corrigan J, Wolcott J, Erickson S. (editors). Patient Safety: achieving a new standard of care. Washington, DC: National Academies Press; 2004.
  42. Sumwalt R. The sterile cockpit. Aviation Safety Reporting System, 4, 1-4. Available at: http://web.archive.org/web/20070410193354/http://asrs.arc.nasa.gov/directline_issues/dl4_sterile.htm1993;[Retrieved February 1, 2008]
  43. Beyea S. Distractions, interruptions and patient safety. AORN. 2007;86:109–112
  44. Pape T, Guerra D, Muzquiz M. Innovative approaches to reducing nurses' distractions during medication administration. Journal of Continuing Education in Nursing. 2005;36:108–116
  45. Santell J, Cousins D, Hicks R. Distractions contribute to medication errors. Drug Topics Health-System Edition. 2003;Available at: http://www.drugtopics.com[Retrieved December 7, 2007]
  46. Hawryluk M. FDA targets medication errors by requiring bar codes on drugs. Available at: Amednews.com.ama-assn.org/amednews/2004/03/15/gv110315.htm2004;[Retrieved January 8, 2008]
  47. Campbell G, Facchinetti N. Using process control charts to monitor dispensing and checking errors. Am J Health Syst Pharm. 2000;55:946–952
  48. AAP. Prevention of medication errors in the pediatric inpatient setting. American Academy of Pediatrics. Committee on Drugs and Committee on Hospital Care. Pediatrics. 2007;102:428–430
  49. Morris F. Adverse medical events in the NICU: epidemiology and prevention. NeoReviews. 2008;9:e8–e23
  50. Smetzer J. ISMP survey pinpoints weaknesses in medication practices. American Hospital Association, Health Research & Educational Trust and the Institute for Safe Medication Practices. Available at: http://www.medpathways.info [Retrieved December 15, 2007].
  51. Koren G. Trends of medication errors in hospitalized children. J Clin Pharmacol. 2002;42:707–710
  52. Reason J. Human error. Cambridge, UK: Cambridge University Press; 1990;
  53. Institute for Safe Medication Practice Medication Safety Alert! The virtues of independent double checks—they really are worth your time! ISMP. Available at: http://www.ismp.org/Newsletters/acutecare/articles/20030306.asp2003;[Retrieved February 2, 2008]
  54. Sagan S. The problem of redundancy problem: why more nuclear security forces may produce less nuclear security. Risk Analysis. 2004;24:935–936
  55. Smetzer J. Reducing at-risk behavior. Jt Comm J Qual Saf. 2005;31:294–299
  56. Blendon R, DesRoches C, Brodie M. Views of practicing physicians and the public on medical errors. N Engl J Med. 2002;347:1933–1940
  57. Thomas E, Sexton J, Neilands T, et al. The effect of executive walk rounds on nurse safety climate attitudes. BMC Health Serv Res. 2005;5:28
  58. Smetzer J, Cohen M. Lessons from the Denver medication error/criminal negligence case: looking beyond blaming individuals. Hosp Pharm. 1998;33:640–657
  59. Smetzer J. Lesson from Colorado: beyond blaming individuals. Nursing. 1998;98:
  60. Franklin B. Misread label. AHRQ web M&M. Available at: http://webmm.ahrq.gov/case.aspx?caseID=392003;[Retrieved December 15, 2007]
  61. Orenstein C. State cites safety drug lapses at Cedars Sinai. Los Angeles Times, Jan 10, 2008. Available at: http://www.latimes.com/news/local/la-me-cedars10jan10,0,7480226.story [Retrieved January 15, 2008].
  62. Lambert B. State finds that a series of health care violations led to an infant's death. N Y Times. 2002;Available at: http://query.nytimes.com/gst/fullpage.html?res=9C02E1D8173BF936A15756C0A9649C8B63[Retrieved December 20, 2007]
  63. Institute for Safe Medication Practices. Medication Safety Alert, Prevent calculation errors-avoid preparing infusions using the Rule of 6 or Brosleow tape. Horsham, PA: Institute for Safe Medication Practices; 2005. Available at: http://www.ismp.org/Newsletters/acutecare/articles/Feb05.asp [Retrieved December 20, 2007].

PII: S1527-3369(08)00035-4

doi: 10.1053/j.nainr.2008.03.008

Newborn and Infant Nursing Reviews
Volume 8, Issue 2 , Pages 72-82 , June 2008