Medication errors in neonates admitted in intensive care unit and emergency department

Indian J Med Sci. 2009 Apr;63(4):145-51.


Background: Medication is the most common health-care intervention, and the errors arising out of its usage are potentially an avoidable cause of iatrogenic injuries. There are reports of medication errors from neonatal emergency setups.

Aims: To study the medication errors of ordering, dispensing and administering in neonates admitted for emergency care and to compare the errors occurring in the emergency department (ED) with those occurring in the neonatal intensive care unit (NICU) of a teaching hospital in north India.

Primary objective: To study the medication errors in ordering and dispensing for neonates.

Secondary objective: To compare these errors in 2 different settings--ED and NICU.

Materials and methods: We did a retrospective chart review of neonatal prescriptions written in the 4 months from January to April 2004 in the neonatal intensive care unit and the pediatric emergency department. The prescriptions were analyzed from the case records bearing an even registration number, obtained from the hospital 'medical records' section. Medication error was defined as 'any preventable event that occurs in the process of ordering, transcribing, dispensing, administering or monitoring a drug irrespective of whether the injury occurred or potential for injury was present!

Results: A total of 821 prescriptions were analyzed and 81 (9.6%) errors were detected. The error rate was found to be 1.5 (54/38) and 0.7 (27/38) per patient in ED and NICU, respectively, being highly significant in ED. Every tenth prescription had medication error in ordering or dispensing; of this, every sixth prescription in ED and nineteenth prescription in NICU had medication error. Dosing errors were the commonest form of detected errors. None of the errors caused any significant harm to the patient but had the potential to cause severe injury, and majority of these errors were preventable.

Conclusion: Medication errors are common in neonatology; more so, in emergency departments than in the neonatal intensive care units.

MeSH terms

  • Emergency Service, Hospital / statistics & numerical data*
  • Hospitals, Teaching / statistics & numerical data
  • Humans
  • India
  • Infant, Newborn
  • Intensive Care Units, Neonatal / statistics & numerical data*
  • Intensive Care, Neonatal / statistics & numerical data*
  • Medication Errors / statistics & numerical data*
  • Retrospective Studies