title: [Medication errors: analysis of a digoxin overdose case in a neonatology unit].
abstract: Neonatology and pediatrics are units where medication errors occur. Indeed, the complexity of nursing care, the lack of information and marketing authorization for drugs contribute to the occurrence of often underestimated iatrogenic events. Through a case of digoxin overdose in a neonatology unit, each stage of the drug circuit was analyzed. From prescription to administration to dispensation, the accumulation of individual errors put a newborn in danger. The analysis and declaration of such events can improve safety and the quality of patient care.
authors.affiliation: Service pharmaceutique, centre hospitalier de Valence, 179, avenue du Maréchal-Juin, 26953 Valence cedex, France. combeclaire@yahoo.fr
authors.forename: C
authors.initials: C
authors.lastname: Combe
authors.forename: R
authors.initials: R
authors.lastname: Girerd
authors.forename: N
authors.initials: N
authors.lastname: Afroukh
authors.forename: M
authors.initials: M
authors.lastname: Vasselon-Raina
authors.forename: H
authors.initials: H
authors.lastname: Hida
mesh_terms: D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D004077:Digoxin / Q000008:administration & dosage / Q000009:adverse effects*; D004232:Diuretics / Q000008:administration & dosage; D062787:Drug Overdose; D011307:Drug Prescriptions; D006344:Heart Septal Defects, Atrial / Q000188:drug therapy*; D006801:Humans; D052577:Infant, Extremely Low Birth Weight; D007231:Infant, Newborn; D007234:Infant, Premature; D007363:Intensive Care Units, Neonatal; D008508:Medication Errors / Q000331:legislation & jurisprudence / Q000517:prevention & control; D061214:Patient Safety; D011787:Quality of Health Care; D012307:Risk Factors
chemical_list: D002316:Cardiotonic Agents; D004232:Diuretics; D004077:Digoxin