Introduction
Methods
Study design
Sample size and sampling method
Data collection
Data analysis
HE
Results
Characteristics of the interviewees
Characteristic | Type of hospital | |
---|---|---|
Governmental | Private | |
Gender | ||
Male | 5 | 3 |
Female | 5 | 2 |
Profession | ||
Pediatrician/neonatologist | 3 | 1 |
Neonatal intensive care nurse | 7 | 4 |
Number of years in practice | ||
< 10 | 3 | 2 |
≥ 10 | 7 | 3 |
Self-reported approximate number of neonatal patients care for per shift | ||
< 8 | 5 | 1 |
≥ 8 | 5 | 4 |
Characteristics of the patients admitted to the neonatal intensive care units
Experiences of the interviewees with medication errors in the neonatal intensive care unit
“…a fully functional system for reporting medication errors and near-misses does not exist in our neonatal intensive care unit. We might file an incidence report when a medication error caused a serious harm to the patient.”
“…..there is no doubt that medication errors are more likely in neonatal intensive care settings. Patients are immature, have a small body size, and are fragile.”
Errors that occurred while preparing/diluting/storing a medication
Errors that occurred while prescribing/administering a medication
# | Category | Medication errors |
---|---|---|
Errors that occurred while preparing/diluting/storing a medication | ||
1 | Calculation errors | A healthcare provider failed to correctly calculate a dose of a medication for a neonate and the final preparation contained an overdose/underdose |
2 | A healthcare provider failed to verify an ambiguous medication preparation order and prepared a dose of a medication for a neonate using cubic centimeters (cc)/milliliters (mL) when milligrams (mg) were intended | |
3 | A healthcare provider failed to verify the correct weight of the neonate and calculated a dose of a medication based on an incorrect weight. The dose resulted in an overdose/underdose | |
4 | Using a wrong solvent/diluent | A healthcare provider failed to adhere to the preparation guidelines and used the wrong solvent instead of distilled water while preparing a dose of potassium chloride for a neonate |
5 | A healthcare provider withdrew sodium bicarbonate instead of amino acids from a look-alike ampule while preparing a dose for a neonate | |
6 | A healthcare provider failed to adhere to the preparation guidelines and used normal saline instead of dextrose while preparing a dose of ertapenem for a neonate | |
7 | Dilution errors | A healthcare provider failed to adhere to the preparation guidelines and diluted a dose of adrenaline that was intended for endotracheal administration for a neonate |
8 | A healthcare provider failed to adhere to the preparation guidelines and did not dilute an intravenous dose of aminophylline that was intended for a neonate | |
9 | A healthcare provider failed to adhere to the preparation guidelines and used an excessive amount of the diluent which resulted in a subtherapeutic dose that was intended for a neonate | |
10 | Failure to adhere to guidelines while preparing a medication | A healthcare provider failed to check the expiry dates of the ingredients used to prepare a dose of a medication that was intended for a neonate |
11 | A healthcare provider failed to check a broken vial/ampoule that contained pieces of glass before using it in preparing a dose of a medication that was intended for a neonate | |
12 | A healthcare provider failed to adhere to the guidelines and did not use different syringes and needles while preparing doses of different medications that were intended for neonates | |
13 | A healthcare provider failed to adhere to the guidelines and prepared a dose of medication that required strict aseptic techniques in a contaminated area | |
14 | A healthcare provider failed to adhere to the guidelines and did not completely dissolve the ingredients leaving precipitates in an intravenous preparation that was intended for a neonate | |
15 | A healthcare provider failed to calibrate the balance used to prepare a dose of a medication for a neonate and the final preparation contained an overdose/underdose | |
16 | Failure to adhere to storage/packaging guidelines | A healthcare provider failed to adhere to the storage guidelines for a light-sensitive medication and the medication was exposed to light for a significantly long time |
17 | A healthcare provider failed to adhere to the storage guidelines and stored a medication in a humid environment while the instructions dictated that the medication should be stored in a dry place | |
18 | A healthcare provider failed to adhere to the storage guidelines and stored a medication at room temperature while the instructions dictated that the medication should be stored in a refrigerator | |
19 | A healthcare provider failed to adhere to the guidelines and packed doses of two different medications using identical packages | |
20 | Failure to adhere to labeling guidelines | A healthcare provider failed to adhere to the guidelines and did label a prepared dose of the medication with the name of the neonate as in the wristband |
21 | A healthcare provider failed to adhere to the guidelines and did label a prepared dose of the medication with the name of the medication | |
22 | A healthcare provider failed to adhere to the guidelines and did label a prepared dose of the medication with the dose | |
23 | A healthcare provider failed to adhere to the guidelines and did label the dose of the medication with the route of administration | |
24 | A healthcare provider failed to adhere to the guidelines and did label a prepared dose of the medication with the date of preparation/expiry | |
Errors that occurred while prescribing/administering a medication | ||
1 | The prescribed/administered medication was not appropriate for the neonate | A healthcare provider failed to check the wristband of a neonate and administered a dose of a medication that was intended for another neonate |
2 | A healthcare provider did not verify the expiry date of the medication and administered a dose of an expired medication to a neonate | |
3 | A healthcare provider failed to check the patient’s allergy notes and prescribed/administered a dose of vancomycin when the notes indicated that the neonate had an allergy to vancomycin | |
4 | A healthcare provider administered two medications for a neonate that were known to have a significant drug-drug interaction | |
5 | A healthcare provider failed to verify an ambiguous medication order and administered a different medication for a neonate from the one that was intended (e.g., ibuprofen when paracetamol/acetaminophen was intended) | |
6 | The administration technique was different from the one that was intended | A healthcare provider failed to verify an ambiguous medication order and administered a dose of a medication for a neonate using a route of administration that was different from the one that was intended (e.g., intravenous prednisolone when inhaled was intended, oral when intravenous was intended, and intramuscular when intravenous was intended) |
7 | A healthcare provider failed to adhere to the administration guidelines and administered a dose of a medication for a neonate using rapid intravenous push when the instructions dictated that the dose had to be administered slowly over a longer period (e.g., fentanyl, potassium chloride, and gentamycin) | |
8 | A healthcare provider failed to insert the cannula correctly and administered a dose of a medication that is known to cause extravasation (e.g., total parenteral nutrition, potassium, calcium, bicarbonate, and high concentration dextrose) | |
9 | A healthcare provider failed to adhere to the administration instructions and administered a dose of a medication for a neonate over a shorter/longer period from the one that was intended (e.g., administration for 10 min when administration for 30 min was intended) | |
10 | A healthcare provider failed to verify if the cannula was open and started administering the medication while the cannula was closed | |
11 | The administered dose was different from the one that was intended | A healthcare provider failed to adhere to the prescription/administration instructions and forgot to administer the medication to the neonate |
12 | A healthcare provider failed to verify an ambiguous medication order for a neonate and administered a dose of 10 mg morphine when 1 mg was intended | |
13 | A healthcare provider failed to verify an ambiguous medication order for a neonate and administered the medication at a frequency that was different from the one that was intended (e.g., every 3 h instead of every 6 h or every 6 h instead of every 3 h) | |
14 | A healthcare provider failed to program the intended infusion rate on an infusor or used the infusion rate that was programmed for the previous medication | |
15 | A healthcare provider failed to adhere to the prescription/administration instructions and administered the calculated maintenance dose instead of the loading dose for a neonate | |
Errors that occurred after administering a medication (monitoring errors) | ||
1 | Failure to adhere to monitoring guidelines | A healthcare provider failed to adhere to the monitoring guidelines and failed to monitor renal function after a dose of a medication that caused nephrotoxicity in a neonate (e.g., vancomycin) |
2 | A healthcare provider failed to adhere to the monitoring guidelines and failed to monitor heart rate after administering a dose of a medication to a neonate that caused cardiac arrhythmias (e.g., calcium gluconate, potassium chloride, and fentanyl) |