The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety...
Stavroudis TA, Shore AD, Morlock L, et al. J Perinatol. 2010;30:459-68.
Medication errors are common in neonatal intensive care unit (NICU) settings. This study used data from MEDMARX, a voluntary reporting system for medication errors, to analyze the underlying causes of adverse drug events in the NICU. While most errors did not cause patient harm, prescribing errors, errors involving malfunctioning equipment, and errors associated with known high-risk medications were more likely to cause clinical consequences. Most errors were ascribed to human factors causes. While prior research has found that computerized provider order entry (CPOE) can reduce medication errors in the NICU, it is notable that nearly half the reported errors in this study occurred during medication administration, and therefore would not have been prevented by CPOE.
Using a case report, the authors discuss a series of errors and illustrate the concepts of active and latent failures. They suggest systems-oriented improvements to both the technique and catheter kit used.
Please select your preferred way to submit a case. Note that even if you have an account, you can still choose to submit a case as a guest. And if you do choose to submit as a logged-in user, your name will not be publicly associated with the case. Learn more information here.