title: Medication errors in a neonatal intensive care unit.
abstract: OBJECTIVE
  To determine the incidence and type of medical errors in a newborn intensive care unit and the relationship between the error and the patient's clinical status.
  
  
  METHODS
  We reviewed the medical charts, during the first 7 days of hospitalization, of all high-risk newborn infants admitted for a period of 3 months.
  
  
  RESULTS
  Seventy-three patients were admitted during the study period. Their mean birth weight was 2,140 g (640-5,020 g) and mean gestational age was 34 weeks (25-40 weeks). Of 73 medical charts analyzed, 40 (55%) had one or more errors. A total of 365 days of hospitalization was analyzed and 95 medical errors were detected (one error per 3.9 days of hospitalization). The most frequent error was associated with medication use (84.2%). Use of therapeutic procedures (drugs, phototherapy, etc.) without proper prescription in the patient's chart (commission error) accounted for 7.4% of the errors, and incidence of omission errors was 8.4%. Incidence of medical errors was significantly higher in newborn infants with lower gestational age.
  
  
  CONCLUSIONS
  Incidence of errors in the care of high-risk newborn infants is elevated. Strategies to improve education of health professionals involved in the care and development of local culture by disseminating clear, accessible algorithms to guide behavior when errors occur must be encouraged.
authors: Instituto Fernandes Figueira, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, RJ, Brazil.
authors: Renata Bandeira de Melo Escovedo
authors: RB
authors: Lerner
authors: Manoel de
authors: Md
authors: Carvalho
authors: Alan Araújo
authors: AA
authors: Vieira
authors: Jose Maria de Andrade
authors: JM
authors: Lopes
authors: Maria Elisabeth Lopes
authors: ME
authors: Moreira
mesh_terms: D001938:Brazil; D015331:Cohort Studies; D006801:Humans; D015994:Incidence; D007231:Infant, Newborn; D007363:Intensive Care Units, Neonatal / Q000706:statistics & numerical data*; D008508:Medication Errors / Q000145:classification / Q000706:statistics & numerical data*; D012720:Severity of Illness Index