Abstract
Purpose: A revision of the medication-use process intended to reduce errors on a neonatal intensive care unit (NICU) is described.
Summary: 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.
Conclusion: Systematic changes in the medication-use process designed to reduce the opportunity for errors were implemented on an NICU.
Introduction
Despite efforts to prevent them, medication errors occur every day throughout the medication-use process. The ordering, processing, and administration of medications provide multiple opportunities for error in a complex system. In pediatrics, especially neonatal medicine, it is more difficult to recognize inappropriate medication orders, and there is a smaller margin of safety. Most medication doses are based on patient weight or gestational age. A 100-mg/kg dose of ampicillin for a 500-g infant means a total drug amount one fifth of that for a 2500-g infant. Practitioners are used to seeing those different doses on the neonatal intensive care unit (NICU). Because of such large variations in doses, an overdose that would be obvious in an adult patient may go unnoticed in a neonate.
Many authors have reported mechanisms for reducing the opportunity for errors in medicine. Work processes must be made safe at each step of patient care. The primary focus in a system's design should be an attempt to eliminate human error. Should human error still occur, the system must also be designed to identify the error and allow its correction. Although human error is a factor, if the physical, occupational, and social environments are not conducive to error-free health care, they all may contribute to a potentially negative outcome.
Proven mechanisms for reducing medication error include reduced reliance on memory, improved access to information, simplification, standardization, and training. A set of design principles has been described previously. When these principles are used in basic operations, the opportunity for error is reduced.
After two serious medication errors on our 45-bed level III NICU at Saint Luke's Hospital, we systematically reviewed the medication-use process. A multidisciplinary team, including neonatal pharmacy specialists, pharmacy information technologists, neonatologists, and neonatal nurses, critically examined each step of the process and identified areas for improvement. The review included a root-cause analysis of the two serious errors, a survey of the literature pertaining to patient safety, and an assessment of pharmacy policies and procedures and information technology support. Identified opportunities for improvement included changes in pharmacist order entry, standardization of compounding, and availability of unit-specific drug information for pharmacy, medical, and nursing staff members. These processes were further divided into specific procedures and assessed for quality, accuracy, error potential, and ease of use. We then implemented changes in the neonatal medication-use process simultaneously over a three-month period.
This article describes the revision of the medication-use process for our NICU.