Medication errors in neonatal and paediatric intensive-care units.
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.
Raju
T N
TN
Division of Neonatology, University of Illinois Hospital, College of Medicine, Chicago.
Kecskes
S
S
Thornton
J P
JP
Perry
M
M
Feldman
S
S
D002648:Child; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000592:standards*; D015278:Intensive Care Units, Pediatric / Q000592:standards*; D008485:Medical Audit / Q000592:standards; D008508:Medication Errors; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D013997:Time Factors