Educational strategy to reduce medication errors in a neonatal intensive care unit

Acta Paediatr. 2009 May;98(5):782-5. doi: 10.1111/j.1651-2227.2009.01234.x.


Objective: We aimed to evaluate the effect of a comprehensive preventive educational strategy on the number and type of drug errors in the prescription process in a regional neonatal intensive care unit (NICU).

Design: Medication errors during prescription were recorded in a 41 bed, level III regional neonatal unit by a pharmacist. Data were retrieved from handwritten doctor's orders and introduced at bedsite into an e-database. Each prescription, not related to enteral and parenteral nutrition and blood products, was evaluated for dosage, units, route and dosing interval. The study was developed in three phases: pilot phase to know the baseline drug error rate and estimate sample size; pre-intervention (4182 drug orders reviewed); and post-intervention seven months after a comprehensive preventive educational intervention consisting sessions about drug errors and study's aims was implemented.

Results: After the preventive educational intervention was implemented, the prescription error rate and the percentage of registers with one or more incident decreased significantly from 20.7 to 3% (p < 0.001) and from 19.2 to 2.9% (p < 0.001), respectively. Simultaneously, an improvement in correct identification of the prescribing physician was registered (from 1.3 to 78.2%). The rest of items analysed were similar in both periods.

Conclusion: The implementation of a structured preventive educational intervention for health professionals in a regional NICU reduced the medication error rate, possibly by the dissemination of a patient safety culture.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Drug Prescriptions
  • Education, Continuing*
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal / standards*
  • Medication Errors / prevention & control*
  • Medication Errors / statistics & numerical data