Medication errors in neonatal and paediatric intensive-care units

Lancet. 1989 Aug 12;2(8659):374-6. doi: 10.1016/s0140-6736(89)90548-5.


In a 4-year prospective quality assurance study, 315 iatrogenic medication errors were reported among the 2147 neonatal and paediatric intensive-care admissions, an error rate of 1 per 6.8 admissions (14.7%). The frequency of iatrogenic injury of any sort due to a medication error was 66/2147 (3.1%)--1 injury for each 33 intensive-care admissions. 33 (10.5%) errors were potentially serious, 32 (10.2%) caused mild patient injuries, and 1 patient had acute aminophylline poisoning after receiving five intravenous doses of the drug at a dosage ten times higher than prescribed, owing to a calculation error during dilution. A longitudinal monitoring system helps to identify iatrogenic complications due to medication errors and may help in implementing preventive measures.

MeSH terms

  • Child
  • Humans
  • Infant, Newborn
  • Intensive Care Units, Neonatal / standards*
  • Intensive Care Units, Pediatric / standards*
  • Medical Audit / standards
  • Medication Errors*
  • Prospective Studies
  • Quality Assurance, Health Care*
  • Time Factors