Identifying medication errors in neonatal intensive care units: a two-center study

Kaveh Eslami; Fateme Aletayeb; Seyyed Mohammad Hassan Aletayeb; Leila Kouti; Amir Kamal Hardani

Study

Identifying medication errors in neonatal intensive care units: a two-center study

December 4, 2019

Eslami K, Aletayeb F, Aletayeb SMH, et al. BMC Pediatr. 2019;19(1):365.

View more articles from the same authors.

Medication errors are thought to be common in neonatal intensive care units (NICUs). This study compared the incidence of medication errors occurring in two NICUs over a three-month period. Over the study period, there were an average of 3.38 medication errors per patient and three-quarters of neonates experienced at least one error. Preterm neonates experienced medication errors significantly more often than term neonates. Errors in prescription dosage and administration were the most common errors.

PubMed citation

Available at

Related Resources From the Same Author(s)

Information transfer at hospital discharge: a systematic review.

April 15, 2020

The impact of computerized physician medication order entry in hospitalized patients—a systematic review.

June 25, 2008

Evaluation of outpatient computerized physician medication order entry systems: a systematic review.

May 16, 2007

Interventions to reduce the incidence of medical error and its financial burden in health care systems: a systematic review of systematic reviews.

August 31, 2022

Evaluation and comparison of errors on nursing notes created by online and offline speech recognition technology and handwritten: an interventional study.

June 15, 2022

Production pressure and its relationship to safety: a systematic review and future directions.

January 18, 2023

Impact of hospital accreditation on quality improvement in healthcare: a systematic review.

January 17, 2024

Normal neurologic and developmental outcome after an accidental intravenous infusion of expressed breast milk in a neonate.

January 25, 2006

Cutting-edge efforts in surgical patient safety.

June 14, 2017

Hospital safety scores: do grades really matter?

June 11, 2014

The impact of rudeness on medical team performance: a randomized trial.

September 30, 2015

Burnout and secondary traumatic stress in health-system pharmacists during the COVID-19 pandemic.

June 30, 2021

The elephant of patient safety: what you see depends on how you look.

August 25, 2010

Deaths due to medical error: jumbo jets or just small propeller planes?

August 8, 2012

The frustrating case of incident-reporting systems.

May 20, 2009

Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?

December 1, 2021

Impact of the COVID-19 pandemic on cancer care: a global collaborative study.

November 11, 2020

The effect of medication reconciliation in elderly patients at hospital discharge.

January 30, 2005

Preventing medication errors in pediatric anesthesia: a systematic scoping review.

November 9, 2022

Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children.

August 26, 2009

Timing of the diagnosis of attention-deficit/hyperactivity disorder and autism spectrum disorder.

October 21, 2015

Time out—charting a path for improving performance measurement.

April 25, 2018

Rapid response teams as a patient safety practice for failure to rescue.

July 7, 2021

Advancing perinatal patient safety through application of safety science principles using health IT.

April 4, 2018

Learning from high risk industries may not be straightforward: a qualitative study of the hierarchy of risk controls approach in healthcare.

January 31, 2018

Variation in hospital mortality associated with inpatient surgery.

October 14, 2009

Detecting unapproved abbreviations in the electronic medical record.

April 4, 2012

Raising the awareness of inpatient nursing staff about medication errors.

October 10, 2007

Unexpected intraoperative patient death: the imperatives of family- and surgeon-centered care.

February 20, 2008

Evidence-based medicine: a cornerstone for clinical care but not for quality improvement.

May 15, 2019

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

Clinicians in quality improvement: a new career pathway in academic medicine.

February 25, 2009

The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety.

March 6, 2005

The problem with root cause analysis.

July 13, 2016

Engineering the system of communication for safer surgery.

February 23, 2011

Using incident reports to assess communication failures and patient outcomes.

April 17, 2019

Retained guidewires in the Veterans Health Administration: getting to the root of the problem.

May 9, 2018

Improving care safety by characterizing task interruptions during interactions between healthcare professionals: an observational study.

October 11, 2023

Estimating deaths due to medical error: the ongoing controversy and why it matters.

October 26, 2016

Trends in adverse events over time: why are we not improving?

March 27, 2013

'Bad apples': time to redefine as a type of systems problem?

June 26, 2013

Root-cause analysis: swatting at mosquitoes versus draining the swamp.

March 22, 2017

A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name.

February 15, 2017

Hospital mortality: when failure is not a good measure of success.

July 30, 2008

Implementing patient safety interventions in your hospital: what to try and what to avoid.

March 12, 2008

The vanishing nonforensic autopsy.

March 12, 2008

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

October 14, 2020

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis.

August 4, 2021

Scoping review of studies evaluating frailty and its association with medication harm.

June 22, 2022

Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm.

April 13, 2022

Inappropriateness of medication prescriptions to elderly patients in the primary care setting: a systematic review.

September 19, 2012

Rates of safety incident reporting in MRI in a large academic medical center.

November 18, 2015

'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds.

March 12, 2014

Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review.

January 12, 2022

Medication use and cognitive impairment among residents of aged care facilities.

June 23, 2021

Prevalence and factors associated with patient-requested corrections to the medical record through use of a patient portal: findings from a national survey.

March 9, 2022

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

August 11, 2010

Improving detection of intraoperative medical errors (iMEs) and intraoperative adverse events (iAEs) and their contribution to postoperative outcomes.

March 6, 2019

Inappropriate prescribing defined by STOPP and START criteria and its association with adverse drug events among hospitalized older patients: a multicentre, prospective study.

August 28, 2019

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

November 24, 2021

Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric?

August 5, 2015

Quality improvement in medical education: current state and future directions.

January 18, 2012

Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research.

March 25, 2020

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

November 1, 2006

The tension between needing to improve care and knowing how to do it.

August 15, 2007

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

July 18, 2007

The association between night or weekend admission and hospitalization-relevant patient outcomes.

January 26, 2011

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.

July 1, 2009

An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery.

October 24, 2012

Development and testing of tools to detect ambulatory surgical adverse events.

June 5, 2013

Identification of common themes from never events data published by NHS England.

April 14, 2021

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

Adverse events during intrahospital transport of critically ill children: a systematic review.

February 12, 2020

Primary care physicians' willingness to disclose oncology errors involving multiple providers to patients.

November 25, 2015

Improving physician's hand over among oncology staff using standardized communication tool.

February 22, 2017

Patient safety at the crossroads.

May 4, 2016

Improving patient safety: moving beyond the "hype" of medical errors.

October 26, 2005

Vulnerability of the medical product supply chain: the wake-up call of COVID-19.

November 25, 2020

Can patients contribute to safer care in meetings with healthcare professionals? A cross-sectional survey of patient perceptions and beliefs.

May 15, 2019

The prevalence of wrong level surgery among spine surgeons.

January 30, 2008

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.

December 10, 2008

Interpersonal and organizational dynamics are key drivers of failure to rescue.

December 5, 2018

Cardiopulmonary arrest and mortality trends, and their association with rapid response system expansion.

August 13, 2014

Usability evaluation of order sets in a computerized provider order entry system.

August 24, 2011

Does user-centred design affect the efficiency, usability and safety of CPOE order sets?

May 4, 2011

Medication reconciliation during transitions of care as a patient safety strategy: a systematic review.

March 20, 2013

Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives.

January 31, 2024

Safe but sound: patient safety meets evidence-based medicine.

April 12, 2006

Identifying risks and opportunities in outpatient surgical patient safety: a qualitative analysis of Veterans Health Administration staff perceptions.

January 31, 2018

Using estimated true safety event rates versus flagged safety event rates: does it change hospital profiling and payment?

May 21, 2014

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

July 30, 2008

Information transfer and communication in surgery: a systematic review.

August 11, 2010

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

April 1, 2009

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals.

July 10, 2019

COVID-19: to be or not to be; that is the diagnostic question.

July 8, 2020

Clinical problem-solving. Lost in transcription.

October 18, 2006

Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.

March 27, 2005

The use of human factors methods to identify and mitigate safety issues in radiation therapy.

December 22, 2010

Increasing compliance with the World Health Organization surgical safety checklist—a regional health system's experience.

October 11, 2017

Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review.

April 26, 2023

Related Resources

Changes in perceptions of antibiotic stewardship among neonatal intensive care unit providers over the course of a learning collaborative: a prospective, multisite, mixed-methods evaluation.

March 20, 2024

Evaluating independent double checks in the pediatric intensive care unit: a human factors engineering approach.

February 21, 2024

Nurses' perception of medication administration errors and factors associated with their reporting in the neonatal intensive care unit.

January 17, 2024

WebM&M Cases

A Complicated Course: Severe Alcohol Withdrawal with Dexmedetomidine Infusion.

July 31, 2023

Error disclosure in neonatal intensive care: a multicentre, prospective, observational study.

May 10, 2023

The relationship between patient safety culture and the intentions of the nursing staff to report a near-miss event during the COVID-19 crisis.

April 5, 2023

An analysis of prehospital pediatric medication dosing errors after implementation of a state-wide EMS pediatric drug dosing reference.

March 1, 2023

Examining medication ordering errors using AHRQ Network of Patient Safety Databases.

February 22, 2023

Improving administration and documentation of enteral nutrition support therapy in a Veteran Affairs health care system: use of medication administration record and bar code scanning technology.

February 1, 2023

Effect of different interventions to help primary care clinicians avoid unsafe opioid prescribing in opioid-naive patients with acute noncancer pain: a cluster randomized clinical trial.

September 7, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

Evaluation of a second victim peer support program on perceptions of second victim experiences and supportive resources in pediatric clinical specialties using the second victim experience and support tool (SVEST).

November 3, 2021

A system safety approach to assessing risks in the sepsis treatment process.

September 22, 2021

Pharmacist-led educational interventions provided to healthcare providers to reduce medication errors: a systematic review and meta-analysis.

August 4, 2021

Integrating and evaluating the data quality and utility of smart pump information in detecting medication administration errors: evaluation study.

November 4, 2020

Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database.

October 14, 2020

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients.

August 19, 2020

The tradeoffs between safety and alert fatigue: data from a national evaluation of hospital medication-related clinical decision support.

July 29, 2020

The impact of technology on prescribing errors in pediatric intensive care: a before and after study.

June 3, 2020

Prevalence and nature of medication errors and preventable adverse drug events in paediatric and neonatal intensive care settings: a systematic review.

December 11, 2019

Smart pumps improve medication safety but increase alert burden in neonatal care

December 4, 2019

Using video to assess and improve patient safety during simulated and actual neonatal resuscitation.

October 30, 2019

Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.

August 14, 2019

Evaluating a handheld decision support device in pediatric intensive care settings.

July 17, 2019

The emotional impact of errors or adverse events on healthcare providers in the NICU: the protective role of coworker support.

April 25, 2018

Designing and evaluating an automated system for real-time medication administration error detection in a neonatal intensive care unit.

February 21, 2018

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Sustained user engagement in health information technology: the long road from implementation to system optimization of computerized physician order entry and clinical decision support systems for prescribing in hospitals in England.

November 1, 2017

Incidence and severity of prescribing errors in parenteral nutrition for pediatric inpatients at a neonatal and pediatric intensive care unit.

October 4, 2017

Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections.

June 14, 2017

See More About The Topic

Intensive Care Units

Facility and Group Administrators

Neonatology and Intensive Care

Ordering/Prescribing Errors

Administration Errors

Identifying medication errors in neonatal intensive care units: a two-center study

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Identifying medication errors in neonatal intensive care units: a two-center study

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site