NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit

J Perinatol. 2010 Jul;30(7):459-68. doi: 10.1038/jp.2009.186. Epub 2009 Dec 31.


Objective: To identify a risk profile for harmful medication errors in the neonatal intensive care unit (NICU).

Study design: A retrospective cross-sectional study on NICU medication error reports submitted to MEDMARX between 1 January 1999, and 31 December 2005. The Rao-Scott modified chi(2) test was used for analysis.

Result: 6749 NICU medication error reports were submitted by 163 health-care facilities. Administering errors accounted for approximately one half of errors, and human factors were the most frequently cited cause of error. Patient age was not associated with an increased likelihood of an error being harmful (P=0.11). Error reports involving Institute for Safe Medication Practices (ISMP) High-Alert Medications, occurring in the prescribing phase of medication processing, or involving equipment/delivery device failures were more likely to be harmful (P< or =0.05).

Conclusion: Risk factors for harmful medication error reports include use of ISMP High-Alert Medications, the prescribing phase of the medication use process, and failure of equipment/delivery devices.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Cross-Sectional Studies
  • Equipment Failure
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal*
  • Medication Errors / statistics & numerical data*
  • Practice Patterns, Physicians'*
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors