title: [Medication errors in a neonatal unit: One of the main adverse events].
abstract: BACKGROUND
  Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented.
  
  
  METHODS
  An analysis was performed on the ME declared in a neonatal unit.
  
  
  RESULTS
  A total of 511 MEs have been reported over a period of seven years in the neonatal unit. The incidence in the critical care unit was 32.2 per 1000 hospital days or 20 per 100 patients, of which 0.22 per 1000 days had serious repercussions. The ME reported were, 39.5% prescribing errors, 68.1% administration errors, 0.6% were adverse drug reactions. Around two-thirds (65.4%) were produced by drugs, with 17% being intercepted. The large majority (89.4%) had no impact on the patient, but 0.6% caused permanent damage or death. Nurses reported 65.4% of MEs. The most commonly implicated causal factor was distraction (59%). Simple corrective action (alerts), and intermediate (protocols, clinical sessions and courses) and complex actions (causal analysis, monograph) were performed.
  
  
  CONCLUSIONS
  It is essential to determine the current state of ME, in order to establish preventive measures and, together with teamwork and good practices, promote a climate of safety.
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España. Electronic address: mtesque@gmail.com.
authors.forename: M T
authors.initials: MT
authors.lastname: Esqué Ruiz
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: M G
authors.initials: MG
authors.lastname: Moretones Suñol
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: J M
authors.initials: JM
authors.lastname: Rodríguez Miguélez
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: E
authors.initials: E
authors.lastname: Sánchez Ortiz
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: M
authors.initials: M
authors.lastname: Izco Urroz
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: M
authors.initials: M
authors.lastname: de Lamo Camino
authors.affiliation: Servicio Neonatología, ICGON, BCNatal, Hopital Clínic sede Maternitat, Universidad de Barcelona, España.
authors.forename: J
authors.initials: J
authors.lastname: Figueras Aloy
mesh_terms: D064420:Drug-Related Side Effects and Adverse Reactions / Q000453:epidemiology; D006801:Humans; D007363:Intensive Care Units, Neonatal; D008508:Medication Errors / Q000706:statistics & numerical data*
keywords: Acontecimientos adversos; Administration errors; Adverse events; Critical incident reporting; Cultura de seguridad; Culture of safety; Declaración de acontecimientos adversos; Drug safety; Errores de administración; Errores de medicación; Errores de prescripción; Errores de tratamiento; Medication errors; Newborn; Prescription errors; Prevención; Prevention; Recién nacido; Seguridad en la medicación; Treatment errors