Med Error Prevention in Neonates

Introduction

Pediatric patients are at relatively high risk of being harmed when medication errors occur.1 Neonates are at even higher risk than older children.2 Dosing errors appear to be the most common type of medication errors in neonatal intensive care units, occurring in both the prescribing and administration phases.2 A recent safety initiative to help reduce dosing errors in neonates comes from the Institute for Safe Medication Practices (ISMP) in collaboration with Vermont Oxford Network, promoting the standardization of neonatal drug infusion concentrations across hospitals.3 This document reviews the new medication safety initiative for neonates.

Standardization of Neonatal Drug Infusion Concentrations

ISMP has published a list of neonatal drug infusion concentrations that was conceived for use by all hospitals that care for neonates. The list includes injectable drugs given by continuous infusion such as dopamine, epinephrine, etc. and injectable drugs given by intermittent infusion such as cefazolin, gentamicin, etc.3

The standard drug infusion concentrations are meant to be appropriate for at least 80% of neonates. The authors of the list recognize the potentially wide variation in weights among neonates, and the need for occasional exceptions to the standards because of this.4

Standardizing neonatal drug infusion concentrations across hospitals is another step in improving the safety of injectable drugs in neonates. In the mid-2000’s, The Joint Commission mandated limiting the number of infusion concentrations available in hospitals. This forced hospitals to stop using patient-specific concentrations, calculated by methods such as the “rule of six.”5 (The “rule of six” was a way to calculate drug infusion concentrations based on patient weight, where 1 mL/hr of the drug infusion will be equal to 1 mcg/kg/min.)

Importantly, the goals of implementing standard drug infusion concentrations for neonates across hospitals are three-fold: to reduce errors such as prescribing and pump programming errors, including when critically ill babies are transferred from hospital to hospital; to make the creation of standard drug libraries for infusion pumps more practical; and to stimulate drug manufacturers to make more premixed drug infusions available.3

ISMP Canada in collaboration with other organizations is working to improve medication safety in hospitalized pediatric patients as well.1 In 2009, a list of the top five medications associated with errors in pediatric patients was published. These included: morphine, potassium chloride, insulin, fentanyl, and salbutamol (albuterol). Fentanyl and morphine accounted for about one-half of the medication errors reported with these top five drugs.6 As such, improving safety with opioid use in pediatrics, including the use of standard concentrations of opioids, has been a priority.7

Conclusion

Experts agree that standardizing neonatal drug infusion concentrations is a step in the right direction for improving medication safety in the most tiny and vulnerable patients. Consider assessing your own practice to see where this list can help make improvements.

The full list of neonatal standard drug infusion concentrations from ISMP/Vermont Oxford Network is available at http://www.ismp.org/Tools/PediatricConcentrations.pdf.

Project Leader in preparation of this PL Detail-Document: Stacy A. Hester, R.Ph., BCPS, Assistant Editor

References

  1. ISMP Canada. A national collaborative: Advancing medication safety in paediatrics. http://www.ismp-canada.org/CurrentProjects/Paediatrics/. (Accessed April 14, 2011).
  2. Chedoe I, Molendijk HA, Dittrich S, 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.
  3. Institute for Safe Medication Practices and Vermont Oxford Network. Standard concentrations of neonatal drug infusions. 2011. http://www.ismp.org/Tools/PediatricConcentrations.pdf. (Accessed April 14, 2011).
  4. Institute for Safe Medication Practices. January-March 2011 Quarterly Action Agenda. Volume 16, Issue 7. April 7, 2011.
  5. JCAHO’s compliance expectations for standardized concentrations. Rule of Six in pediatrics does not meet requirements. Jt Comm Perspect 2004;24(5):11.
  6. ISMP Canada Safety Bulletin. National collaborative: top 5 drugs reported as causing harm through medication errors in paediatrics. August 31, 2009. http://www.ismp-canada.org/download/safetyBulletins/ISMPCSB2009-6-NationalCollaborative-Top5DrugsReported.pdf. (Accessed April 14, 2011).
  7. ISMP Canada. Canadian paediatric high alert medication delivery: opioid safety. January 28, 2010. http://www.ismp-canada.org/CurrentProjects/Paediatrics/downloads/ISMPC_CAPHC_Paediatrics_Phase_2_Report_final.pdf. (Accessed April 14, 2011).

Cite this document as follows: PL Detail-Document, Med Error Prevention in Neonates. Pharmacist’s Letter/Prescriber’s Letter. May 2011.

Related Articles