Home Print this page Email this page Small font sizeDefault font sizeIncrease font size
Users Online: 458
About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Advertise Login 

 Table of Contents  
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 113-116

Reducing medication errors on a busy tertiary neonatal intensive care unit using a quality improvement approach

1 Division of Neonatal, Corniche Hospital, Abu Dhabi, United Arab Emirates
2 Department of Pharmacy, Corniche Hospital, Abu Dhabi, United Arab Emirates
3 Department of Information Technology, Corniche Hospital, Abu Dhabi, United Arab Emirates

Date of Submission12-Aug-2020
Date of Acceptance06-Jan-2021
Date of Web Publication15-May-2021

Correspondence Address:
Chokkiyil Ponnambath Hafis Ibrahim
Division of Neonatal, Corniche Hospital, P. O. Box: 3788, Abu Dhabi
United Arab Emirates
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcn.jcn_130_20

Rights and Permissions

Objectives: Due to a high rate of reported medication errors on our neonatal intensive care unit (NICU), a quality improvement project was undertaken to tackle the problem in 2015. The steps included the development of a customized formulary, which was aligned to the electronic prescribing system and the smart pump libraries. The incidence of medication errors after serial introduction of the interventions was studied. Methods: Data on medication errors were extracted from the online incident reporting system. Additional data were derived from the pharmacy database. Trend on errors for the whole year was analyzed. Results: The medication error rate fell from 25.7/1000 to 6.7/1000 patient-days with the implementation of the project which was sustained even after the project implementation was complete. There was a statistically significant reduction in the rate of medication errors over the course of the year. Conclusions: Medication errors are common in neonatal care. A quality improvement approach with enhancements of existing systems significantly reduced the reported medication errors on the local NICU.

Keywords: Medication errors, neonatal intensive care, patient safety, quality improvement

How to cite this article:
Ibrahim CP, Ofoegbu B, Yahya L, Catroon K, Al Masri DA, Saliba A, Ghassa L. Reducing medication errors on a busy tertiary neonatal intensive care unit using a quality improvement approach. J Clin Neonatol 2021;10:113-6

How to cite this URL:
Ibrahim CP, Ofoegbu B, Yahya L, Catroon K, Al Masri DA, Saliba A, Ghassa L. Reducing medication errors on a busy tertiary neonatal intensive care unit using a quality improvement approach. J Clin Neonatol [serial online] 2021 [cited 2023 Jan 30];10:113-6. Available from: https://www.jcnonweb.com/text.asp?2021/10/2/113/316170

  Introduction Top

Medical errors contribute to a significant amount of mortality and morbidity in healthcare.[1] Medication-related errors constitute a significant proportion of these.[2] It has been estimated that in the neonatal population, up to 47% of all the reported errors are medication-related.[3] Newborn infants are at a higher risk of medication errors due to the complexity of processes involved in their medication management including significant off label use medications and also weight, postnatal age, and gestation-based dosing.[3],[4]

The hospital where the study was conducted hosts the largest neonatal service in the United Arab Emirates with a cot capacity of 64 and nearly 1000 admissions annually, of which approximately a quarter are very low birth weight infants. The unit runs at near 100% capacity most of the time. Nearly 100–120 medications are prescribed and 400–600 doses administered to the infants every day.

In early 2015, an analysis of the reported medication errors over the previous quarter revealed that the rate of errors were 34.2/1000 patient days. This was higher than internationally reported rates (5.1–24.1/1000 patient days).[5],[6],[7] In this article, we report a quality improvement project (QIP) with serial incremental interventions implemented at our hospital over a 1 year period aimed at reducing medication errors on the neonatal intensive care unit (NICU).

  Methods Top

A multidisciplinary team consisting of neonatologists, clinical pharmacists, neonatal nurses, and an information technology specialist was constituted to identify the root causes for the high rate of medication errors in the department, formulate appropriate solutions and implement them.

Prior to initiation of the QIP, the reported medication errors in 2014 were analyzed. The most commonly reported errors were prescribing errors. A root cause analysis of the reported errors was conducted focusing on every step of the medication management process including prescription, dispensing, logistics, patient identification, and drug administration. The existing controls and their weaknesses in relation to the root causes were identified [Table 1].
Table 1: Root causes identified contributing to medication errors on the neonatal intensive care unit

Click here to view

Solution development

The solutions were focused on the four main root causes identified as detailed in [Table 1].

Development of unified local neonatal formulary

A bespoke quick reference formulary was developed as the first step. Standardized information was developed for each drug, using guidance from published formularies and current evidence from literature. The information included specifics of dosage, scheduling, administration, and preparation for each medication. Condensed data sheets were developed for each medication containing relevant information for all stakeholders including prescribers, pharmacists, and bedside nurses. The syringe sizes for majority of infusions were reduced from 50 mL to 25 mL (except where required to avoid several syringe changes in a 24 h period usually anticipated with bigger babies) to limit the risk of accidental fluid overload in cases of incorrect pump programming.

Alignment of computerized physician order entry system to formulary

In parallel with developing the datasheets for each drug, the IT specialist in the team built ordering options within the Computerized Physician Order Entry (CPOE) which were aligned to the information on each drug in the formulary. Single click order sets were built for drugs that required initial loading doses (e.g. caffeine and teicoplanin) followed by maintenance doses and for drugs that required phased decremental doses (e.g. dexamethasone in DART protocol).

Alignment of smart infusion pumps to computerized physician order entry and formulary

The Alaris™ smart infusion pumps with the Guardrails® software are used on our NICU. Although they had a reasonably comprehensive library of medications (of standard concentrations) which mainly included continuous infusions, physicians prescribed different concentrations of drugs depending on personal preference and also on the reference they were using. This led to many infusions being prepared with concentrations outside of the drug library limits and the nurses having to program the infusion in manually leading to error. To avoid this, database on the pumps was updated to match the data of each drug in the formulary and CPOE.

Clinical pharmacist support

The neonatal department had one clinical pharmacist providing support to the frontline clinicians for medication management. An additional pharmacist was made available as part of the QIP. The pharmacists accompanied clinicians on ward rounds.

Statistical analysis

All the infants admitted to the neonatal unit during 2015 were included as potential patients. Data were collected on all the medication errors reported during 2015 from the electronic error reporting system. The data on the number of medications prescribed and administered was ascertained from the CPOE and electronic patient records. The data were extracted on to an Excel database for analysis. An epoch analysis for 2 months each at the inception of the QIP (Period 1), mid-way (Period 2), and completion (Period 3) was done to assess the impact of the multiple measures which were put in place. The rate of errors was analyzed using Chi-square test or Fischer's exact test.

As this was an audit of practice it was exempt from informed consent and approved by the institutional review board.

  Results Top

There was a downward trend in the rate of reported errors over the course of 2015 from a peak of 25.7 per 1000 patient days in the first quarter to 6.7 per 1000 patient days by the last quarter of 2015 [Figure 1]. This reduction was sustained in the subsequent year. The results from the timed epoch analysis are summarized in [Figure 2]. There were between 6500 and 6700 individual prescriptions and 26000–35000 doses administered per each 2 month period analyzed. Prescription errors outnumbered the administration errors. There was a significant reduction in both prescription and administration errors across the three epochs.
Figure 1: Trends in medication errors over the course of the quality improvement project and subsequent year

Click here to view
Figure 2: Timed-epoch analysis of medication errors during the course of project implementation

Click here to view

  Discussion Top

Medication errors contribute significantly to patient morbidity and mortality which are potentially preventable.[8],[9] In the past few decades, there has been a concerted effort from healthcare organizations and regulators to develop safe healthcare systems to reduce harm to patients from preventable errors with varying levels of success. Medication errors have been an area which has been focused on intensely across all medical specialties. The most common medication errors reported in pediatrics and neonatology are related to physician prescribing (74%–76%) including dosing, frequency, and route of administration.[10]

CPOE has been proven to be an effective way of reducing medication errors in the adult population by as much as 55%–88%.[11] A CPOE was already in place at our hospital at the inception of the QIP. However, the decision support for most of the neonatal medications and their dosing was limited. The development of a bespoke neonatal formulary has aided our physicians, nurses, and pharmacists while using the electronic systems in parallel. Enhancements were made on the CPOE to guide weight, gestation and postnatal age-based dosing aligned to the formulary recommendations. Some of the CPOE enhancements were phased in prior to the release of the final version of the neonatal formulary. The impact of this can be seen in the reduction in the reported errors between the first and second quarters of 2015. This is an example of how cumulative CPOE enhancements even after initial implementation are necessary to continuously improve medication error rates as reported by other authors.[11],[12]

Infusion pumps have been in use in healthcare for over four decades. Smart pumps with built in dose error reduction software and drug libraries have become increasingly common place in the West and are gradually being adopted into evolving health care economies.[13] The success of smart pumps depends on the strength of the drug library in the background, compliance with the library, and the alerts built in.[13] Due to the complexity of weight-based dosing and infusion rates, a combination of standard drug concentrations for infusions and smart pump technology have proven to reduce errors from continuous infusions in children.[14] As part of the QIP, the team standardized the concentrations and syringe sizes of all continuous infusions to suit all weight ranges limiting the choices for each medication available on the CPOE to the prescribers and the choices on the pumps for the bedside nurses. The drug library was expanded and completely aligned with the formulary and CPOE. This has contributed to the significant reduction in medication errors related to administration errors though the reported numbers were small even before the start if the QIP [Figure 2].

Our study is limited by the way the data on errors were collected entirely from a voluntary error reporting system. It is recognized that only <10% of errors (including medication related) are voluntarily reported.[15] However, trends can be identified within a study period as long as variables such as type of reporting systems and composition of the stakeholders (and therefore human behaviors) do not change. These variables remained constant which allows us to conclude that the QIP resulted in a significant and sustained reduction in medication errors on our NICU.

  Conclusions Top

Medication errors are common in neonatal intensive care. A multi-modality quality improvement approach with enhancements of existing systems significantly improved patient safety and reduced the reported medication errors from 25.7 to 6.7 per 100 patient days within 1 year of initiation of the project on the local NICU.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kohn LT, Corrigan JM, Donaldson MS, editors. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.  Back to cited text no. 1
de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: A systematic review. Qual Saf Health Care 2008;17:216-23.  Back to cited text no. 2
Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shiono PH, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics 2004;113:1609-18.  Back to cited text no. 3
Chedoe I, Molendijk HA, Dittrich ST, Jansman FG, Harting JW, Brouwers JR, et al. Incidence and nature of medication errors in neonatal intensive care with strategies to improve safety: A review of the current literature. Drug Saf 2007;30:503-13.  Back to cited text no. 4
Snijders C, van Lingen RA, Molendijk A, Fetter WP. Incidents and errors in neonatal intensive care: A review of the literature. Arch Dis Child Fetal Neonatal Ed 2007;92:F391-8.  Back to cited text no. 5
Simpson JH, Lynch R, Grant J, Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed 2004;89:F480-2.  Back to cited text no. 6
Vincer MJ, Murray JM, Yuill A, Allen AC, Evans JR, Stinson DA. Drug errors and incidents in a neonatal intensive care unit. A quality assurance activity. Am J Dis Child 1989;143:737-40.  Back to cited text no. 7
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.  Back to cited text no. 8
Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995;10:199-205.  Back to cited text no. 9
Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in paediatric inpatients. JAMA 2001;285:2114-20.  Back to cited text no. 10
Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-21.  Back to cited text no. 11
Kazemi A, Ellenius J, Pourasghar F, Tofighi S, Salehi A, Amanati A, et al. The effect of Computerized Physician Order Entry and decision support system on medication errors in the neonatal ward: experiences from an Iranian teaching hospital. J Med Syst 2011;35:25-37.  Back to cited text no. 12
Ohashi K, Dalleur O, Dykes PC, Bates DW. Benefits and risks of using smart pumps to reduce medication error rates: a systematic review. Drug Saf 2014;37:1011-20.  Back to cited text no. 13
Larsen GY, Parker HB, Cash J, O'Connell M, Grant MC. Standard drug concentrations and smart-pump technology reduce continuous-medication-infusion errors in pediatric patients. Pediatrics 2005;116:e21-5.  Back to cited text no. 14
Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, et al. Adverse events in the neonatal intensive care unit: Development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics 2006;118:1332-40.  Back to cited text no. 15


  [Figure 1], [Figure 2]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded196    
    Comments [Add]    

Recommend this journal