title: A summary of NICU fat emulsion medication errors and nursing services: data from MEDMARX.
abstract: Intralipid infusions remain a critical part of ensuring adequate nutritional supplement and growth in premature and term infants. Managing intralipid therapy requires great care to prevent metabolic and physiological side effects. The authors sought to systematically study medication errors associated with intralipid administration in the neonatal intensive care unit (NICU). A descriptive quantitative and qualitative analysis incorporating secondary data was used. Medication error data were drawn from 54 institutions that voluntarily participated with MEDMARX, a national, Internet-accessible medication error reporting program owned and operated by the United States Pharmacopeia. These errors were associated with NICUs, and each medication error record identified nursing staff as making the initial error. A total of 257 errors were reviewed, with 3.9% resulting in harm. The mean age of the neonate was 7 days, and more errors occurred on Mondays than any other day of the week. Errors disproportionately occurred between 6 pm and midnight, with a significant difference between errors near 7 am and 7 pm (P = .002). Wrong dose errors occurred in 69% of the sample. Nearly one quarter of the errors resulted from misprogramming infusion devices (either pumps or syringes). Qualitative findings revealed that many of the errors were the result of the nurse's misinterpretation of the modes (ie, time, volume, or rate) on the infusion device or by not recognizing the decimal point on the device's display panel. Several errors involved switching the rate of infusion with total parenteral nutrition and that of intralipids. Voluntary medication error reporting offers valuable insights into intralipid errors occurring in NICUs. Secondary analysis is an ethical, economic means of studying the occurrence of such errors. MEDMARX data suggest that some of the serious errors are the result of complex care and equipment needed for these vulnerable infants.
authors: The United States Pharmacopeia, Department of Patient Safety, Drug Standards Division, Rockville, MD 20852, USA. rh@usp.org
authors: Rodney W
authors: RW
authors: Hicks
authors: Shawn C
authors: SC
authors: Becker
authors: John
authors: J
authors: Chuo
mesh_terms: D005217:Fat Emulsions, Intravenous / Q000008:administration & dosage* / Q000009:adverse effects; D006801:Humans; D007231:Infant, Newborn; D007234:Infant, Premature; D007260:Infusion Pumps / Q000009:adverse effects; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data; D008508:Medication Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D009732:Nursing Care; D012307:Risk Factors; D012308:Risk Management / Q000706:statistics & numerical data; D013997:Time Factors; D014481:United States
chemical_list: D005217:Fat Emulsions, Intravenous