Errores de prescripción de drogas endovenosas en una unidad de cuidados neonatales de la Ciudad de Buenos Aires

Vera Vanina Serra; Fabiana Pena; María Fabiana Ossorio; Carlos Pedicone; Marcelo Armadans

doi:10.31053/1853.0605.v69.n1.21354

Authors

Vera Vanina Serra Servicio de Neonatología, Instituto Argentino de Diagnóstico y Tratamiento Marcelo T. de Alvear 2346, Buenos Aires.
Fabiana Pena Servicio de Neonatología, Instituto Argentino de Diagnóstico y Tratamiento Marcelo T. de Alvear 2346, Buenos Aires.
María Fabiana Ossorio Departamento de Pediatría, Facultad de Medicina, Universidad de Buenos Aires. Autor responsable: Marcelo Armadans Dirección: Juncal 1455 Ituzaingo (CP1455) Teléfono: 46247928
Carlos Pedicone Servicio de Neonatología, Instituto Argentino de Diagnóstico y Tratamiento Marcelo T. de Alvear 2346, Buenos Aires.
Marcelo Armadans Servicio de Neonatología, Instituto Argentino de Diagnóstico y Tratamiento Marcelo T. de Alvear 2346, Buenos Aires.

DOI:

https://doi.org/10.31053/1853.0605.v69.n1.21354

Keywords:

medication errors, drug prescriptions, infant, mewborn, intensive care, neonatal

Abstract

Background: Although error could be present in almost every medical practice, they are more frequent and potentially more dangerous in neonatal intensive care units (NICU).

Objective: To determine prescription error rate of intravenous drugs in a Neonatal Intensive Care Unit (NICU), and to describe type of error (dose, dilution, and interval) and medication (antibiotics, inotropics, or analgesics).
Methods: Observational study including medical records of patients hospitalized in a NICU, receiving any of the above mentioned drugs. Each prescription was compared with one provided by a specific software. Prescription error was defined as >10% of difference between both values.

Results: 362 prescriptions from 82 patients were analyzed. An error was observed in 42.5% (95%CI 37.4 – 47.8) of all prescriptions, including 148 (96.1%; 95%CI: 91.3-98.4) antibiotics prescriptions, 5 (3.2%; 95%CI: 1.2-7.7) inotropics prescriptions and 1 (0.7%; 95%CI: 0.01-4.2) analgesics prescriptions. Prescription errors were due to frequency error in 53.8% 95%CI: 45.6-61.8 of cases and to volume error in 46.1% (95%CI: 38.1-54.3).

Conclusion: Almost half of the intravenous drugs prescriptions included an error, being more frequently related to interval, followed by dosing; no errors in dilution were detected. Using prescription software could improve patient’s safety.

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References

Ceriani Cernadas J. El error en medicina: reflexiones acerca de sus causas y sobre la necesidad de una actitud más crítica en nuestra profesión. Arch Argent Pediatr. 2001; 99(6): 522-529.

Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, Goldmann DA. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001; 285(16):2114-20.

Campino Villegas A, López Herrera MC, García Franco M, López de Heredia Goya I, Valls i Soler A. Errores en la prescripción y transcripción de medicación en una unidad neonatal. An Pediatr (Barcelona) 2006; 64 (4); 330-335.

Pérez Rodriguez J .Errores médicos en pediatría y neonatología. Un nuevo enfoque multidisciplinario es necesario. An Pediatr (Barcelona) 2006; 64 (4): 327-329.

Clark R, Bloom B, Spitzer A, Gerstman D. Reported medication use in the neonatal intensive care unit: data from a large national data set. Pediatrics. 2006; 117(6):1979 -1987.

Young T, Mangum B. Neofax®: A manual of drugs used in neonatal care, 20th ed. Montvale, NJ: Thomson Healthcare, 2007.

Cordero L, Kuehn L, Kumar R, Mekhjian H. Impact of computerized physician order entry on clinical practice in a newborn intensive care unit. J Perinatol. 2004; 24:88–93. PubMed

Lerner RB, Carvalho M, Vieira AA, Lopes JM, Moreira ME. Medication errors in a neonatal intensive care unit. J Pediatr (Rio J). 2008; 84(2):166-170.

National Coordinating Council on Medication Error Reporting and Prevention. About medication errors. Disponible en: http://www.nccmerp.org/aboutMedErrors.html . Visitado el 06 de diciembre de 2011.

Barroso Pérez C, Juárez Giménez JC, Moraga Llop FA. Errores de medicación. An Pediatr (Barcelona). 2001; 55(6):501-502.

Enriquez D. El error en neonatología. Revista del Hospital Materno Infantil Ramón Sardá. 2003; 22 (001): 19 -21

Ghaleb MA, Barber N, Franklin BD, Wong IC. The incidence and nature of prescribing and medication administration errors in pediatrics inpatients. Arch Dis Child. 2010; 95(2):113-8.

Morriss F. Adverse Medical Events in the NICU Epidemiology and Prevention. NeoReviews 2008; 9(1):e8-e23.

Chedoe I, Molendijk HA, Dittrich ST, Jansman FG, Harting JW, Brouwers JR, Taxis K. Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: a review of the current literature .Drug Saf. 2007;30(6):503-13.

Otero P, Leyton A, Mariani G, Ceriani Cernadas J, Patient Safety Committee. Medication errors in pediatric inpatients: prevalence and results of a prevention program. Pediatrics. 2008 ;122:e737-43.

Sard BE, Walsh KE, Doros G, Hannon M, Moschetti W, Bauchner H. Retrospective evaluation of a computerized physician order entry adaptation to prevent prescribing errors in a pediatric emergency department. Pediatrics. 2008;122(4):782-7.

van Rosse F, Maat B, Rademaker CM, van Vught AJ, Egberts AC, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics 2009; 123(4):1184-90.

Delgado Silveira E, Soler Vigil M, Pérez Menéndez-Conde C, Delgado Téllez de Cepeda L, Bermejo Vicedo T. Errores de prescripción tras la implantación de un sistema de prescripción electrónica asistida. Farm Hosp. 2007; 31(4):223-230.