Computer-Related Medication Errors in Neonatal Intensive Care Units

https://doi.org/10.1016/j.clp.2007.11.005Get rights and content

Iatrogenic medication errors in the neonatal ICU (NICU) are reported to occur up to 2.6 times per 100 NICU days. It has been learned during the last decade that well-intended but faulty implementations of technology can increase the frequency of errors and also can give rise to new types. This article compares and discusses iatrogenic medication errors in the NICU that are related to computer entry and computerized physician order entry systems. The authors also propose a possible approach for evaluating technology that is intended to prevent iatrogenic mediation errors in the NICU.

Section snippets

Medication errors

Medication errors account for as many as 7000 iatrogenic deaths in the United States each year [1]. From the US Food and Drug Administration (FDA) database, known as “MedWatch,” investigators analyzed 7111 pediatric adverse medication error reports received over 5 years between November 1997 and December 2002 [10] and showed an increased vulnerability of younger children, especially those less than 1 year old, to medication errors. In this patient population, 30% of medication errors can lead

Technology and the neonatal ICU medication use process

Although the epidemiology of neonatal medication errors seems to be limited when compared with other populations, this population seems to be at greater risk of medication errors than older children [16]. Neonatal practitioners often face unique challenges in the MUP, for which technology is well suited to assist in decision-making. The MUP is a systems approach that describes the general flow of how medications are ordered, dispensed, and administered (Fig. 1). Without doubt, information

Medication error reporting

USP is a practitioner-based organization that sets legally enforceable standards addressing the strength, purity, labeling, packaging, and storage of therapeutic products. USP has more than 30 years of experience in operating various voluntary reporting programs for purposes of integrating findings into the standards-setting process to fulfill its public health mission. The two medication error reporting programs are the USP- Institute for Safe Medication Practices (ISMP) Medication Errors

Discussion

This study examined NICU medication errors involving either computer entry or CPOE, two important technologies that aim to reduce the burden of iatrogenic errors. Data were reported voluntarily by 48 facilities to a national medication error reporting program.

Limitations of this study

The study presented in this manuscript has numerous limitations. First, all data came from voluntarily reported medication errors. Voluntary reporting generally is considered to result in fewer errors being reported and thus may not be truly representative of all NICU errors. Second, this study did attempt to correlate the errors with institutional characteristics, meaning that the possibility of nesting remains present. The absence of denominator data hindered the analysis. Therefore, no

Summary

Iatrogenic medication errors in the NICU are common in pediatrics and impose a formidable health risk to neonates. Among all participants in the MUP, pharmacists have been among the earliest adopters of technology for error prevention. As dispensing technology became more effective in preventing errors, prescription and transcription errors became even more prominent. Addressing such prepharmacy errors has been the intention of CPOE advocates. Although CPOE seems to have reduced transcription

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    This article was supported in part by U.S. Pharmacopeia, Rockville, MD.

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