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

Journal of Perinatology volume 30, pages 459–468 (2010)Cite this article

Abstract

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 χ2 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⩽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.

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Acknowledgements

We thank Maureen Fahey, MLA for her help with data coding; Panagiotis K Ordoulidis for his assistance in the preparation of this manuscript. This work was supported by the Agency for Healthcare Research and Quality Grant 1R03HS016774-01A1.

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Authors and Affiliations

  1. Eudowood Neonatal Pulmonary Division, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    T A Stavroudis, D Bundy & M R Miller

  2. Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

    A D Shore, L Morlock & M R Miller

  3. Texas Tech University Health Sciences Center School of Nursing, Lubbock, TX, USA

    R W Hicks

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  1. T A Stavroudis
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  2. A D Shore
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  6. M R Miller
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Corresponding author

Correspondence to T A Stavroudis.

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Competing interests

The following authors have no conflict of interest with publication of this paper to report: Theodora A Stavroudis, MD and David Bundy, MD. Andrew D Shore, PhD receives 20% salary support from a United States Pharmacopeia (USP) contract and also has a separate consulting agreement to perform additional analyses as requested by USP. Marlene R Miller, MD, MSc and Laura Morlock, PhD have a research contract with USP to analyze data and have full authority to publish findings of their work without requiring pre-approval from USP. Rodney W Hicks, PhD, ARNP was formerly the Manager of Patient Safety Research at USP and is currently the UMC Health System Endowed Chair for Patient Safety at the Texas Tech University Health Sciences Center School of Nursing.

Additional information

This work was conducted while the first author was a Neonatology Fellow at Johns Hopkins University.

Supplementary Information accompanies the paper on the Journal of Perinatology website

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Stavroudis, T., Shore, A., Morlock, L. et al. NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Perinatol 30, 459–468 (2010). https://doi.org/10.1038/jp.2009.186

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