Improving medication safety in a neonatal intensive care unit.
OBJECTIVE
A revision of the medication-use process intended to reduce errors on a neonatal intensive care unit (NICU) is described.


CONCLUSIONS
A multidisciplinary team conducted a systematic review and implemented multifaceted changes to improve the NICU's medication-use process. These changes were made to improve safety and consistency and make the system more user-friendly. A distinct, unit-specific formulary was created for the drug products used on the NICU. Rules were built into the order-entry computer system for these NICU formulary items to identify doses outside the documented range on the basis of body weight. A unit-specific reference was developed detailing all formulary mnemonics, oral drug compounding and i.v. admixture procedures, and guidelines for appropriate product selection. Emergency medication sheets listing the calculated doses by weight for critical or urgent medications were developed; these sheets are provided for every new admission and are updated weekly. End-product-testing procedures for i.v. admixtures and a medication-checking process for the unit's automated dispensing machine were implemented.


CONCLUSIONS
Systematic changes in the medication-use process designed to reduce the opportunity for errors were implemented on an NICU.
Lucas
Amber J
AJ
Department of Pharmacy, Saint Luke's Hospital of Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA. alucas@saint-lukes.org
D004305:Dose-Response Relationship, Drug; D005500:Follow-Up Studies; D005569:Formularies as Topic; D006801:Humans; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal; D008508:Medication Errors / Q000517:prevention & control*; D011785:Quality Assurance, Health Care; D017751:Safety Management / Q000592:standards*; D014481:United States