Medication errors in NICU

Medication errors in the NICU may be hazardous for newborn patients. Due to the unique nature of newborn physiology, any such errors may cause more damage to a newborn than an adult. Many medications in NICU are used off-label (the FDA did not approve them for use in neonates) and require special dilutions and complicated calculations to come up with the correct dosing. In addition, most medications administered in the NICU will be given via intravenous access and, therefore, will cause immediate effects (source article). 

Published literature on the incidence of pharmacologic errors in NICUs cites a wide range of numbers, the highest being 5.5%. I can put this number in perspective: one out of twenty newborn babies treated in the NICU may be affected. 

However, if we assume that we give 4 or 5 medications to a newborn treated in NICU (that is quite a common situation), even one out of 4-5 babies may be impacted by pharmacologic errors (source article). 

Adverse effects of medication errors will vary a lot and may range from benign rash through organ failures to death of the patient. Historically, the most dangerous mistakes in neonates pertained to using potassium and heparin. 

Potassium is an important electrolyte that we often supplement in intravenous fluids. Elevated potassium levels in our body may lead to cardiac arrest (the heart stops beating). Heparin is a medication that prevents clotting in central lines (intravenous catheters placed close to the heart). When overdosed, heparin may cause life-threatening bleeding. 

The most common medication errors are listed below:

• inappropriate medication prescribed
• wrong medication given
• wrong dose prescribed
• the wrong amount is given despite the properly prescribed dose
• wrong patient (medication was prescribed for another patient)
• wrong route (medication was prescribed to be given by mouth but was administered by injection)
• not checking blood levels if indicated
• lack of proper follow-up for medication side effects

Conducting a neonatal chart review when a bad neonatal outcome may be due to a pharmacologic error is challenging. Often, such mistakes are not reported well and are hidden in charts. Below, I will describe frequent medication errors and comment on their sources. 

Inappropriate medication 

While reviewing a neonatal chart, I ensured that a proper diagnosis was made and doctors treated the patient according to accepted recommendations. 

For example, if a baby is diagnosed with congenital syphilis, the most appropriate treatment for this patient would be Penicillin, not Erythromycin. 

Another example and frequent error: if a baby is in shock during resuscitation, we want to use a normal saline bolus as a volume expander, not a glucose bolus. 

In some areas of neonatology, recommendations regarding specific treatment have yet to be agreed upon, and we continue debating the best approach (for example, treating PDA). Nevertheless, physicians in charge should always indicate the justification for using any medications in their treatment plan. 

Wrong medication given

There may be multiple reasons why a patient received the wrong medicine:

• The physician intended to treat a patient with the right drug but prescribed a different one due to a typing error.
• A pharmacy dispensed the wrong medication.
• A nurse grabbed the wrong bottle or syringe and administered the medicine.
• Labeling problems on the drug dispensed from the pharmacy may confuse doctors and nurses.

Wrong dose of the medication

Newborn babies are tiny and fragile. While certain adult medications are dosed in tablets, capsules, or vials, we must calculate almost all medicines in grams or milligrams per kilogram of body weight for neonates. 

For continuous intravenous infusions, the situation may be even more complicated. Those are often dosed in milligrams or micrograms per kilogram per minute. Doctors, nurses, and pharmacists make many mistakes while calculating and administering continuous intravenous infusions. 

Although electronic medical records help avoid some calculation mistakes, they do not eliminate them. 

The proper dose is prescribed, but the wrong amount of medicine is administered

This type of error may occur in two scenarios. 

First, when pharmacists mix up medication and use erroneous amounts of drugs or dilutants. Another common situation occurs in emergencies when the physician orders medications verbally and the nurse has to draw medicines on her own using medications stocked in the unit. 

Wrong patient

Occasionally, the medication is given to the wrong patient. There are many sources of this error. Examples include:

• A mislabeled syringe.
• A patient without an ID band.
• A nurse failed to check the baby’s ID.
• Somebody moved the patient to a different location.

This error often results from short-staffed units, lack of training, and sloppiness at work. 

Wrong route

Each medication formulation is designed to be administered by a specific route and is not exchangeable. If we are supposed to give a baby multivitamins with iron by mouth, it will be hazardous to inject this medicine intravenously. 

Not checking blood levels when indicated

Some medications used in NICU require close follow-up of their concentrations in the blood after administration to ensure therapeutic and safe levels. Examples of such medicines are gentamicin, vancomycin, or, in some situations, caffeine. 

If we forget to check those levels, the baby may suffer from side effects that could have been avoided with proper follow-up.

Lack of proper follow-up after administration of the medicine

Each medication that doctors use in the NICU has a long list of potential side effects. We must know those adverse effects and appropriately plan to recognize them early. 

Some of the side effects observed in babies in the NICU are listed below:

• skin rashes
• abnormal body temperature
• low blood pressure
• high blood pressure
• decreased urine output
• abnormal potassium levels
• abnormal sodium levels
• glucose abnormalities
• excessive bleedings

Final remarks about pharmacologic errors in NICU

NICU is a very complex environment. Patients are very small; doctors use numerous life-saving medications and sophisticated equipment. Each procedure and medication can help a baby, or it may harm it if inappropriately used. 

Neonatologists and pediatricians are responsible for minimizing risks to their patients. Additionally, hospital administrators must recognize that it is their duty to optimize workflow and introduce safe practices in each hospital setting. 

Proper staffing, training, updated policies, age-appropriate electronic medical records, and infusion pump software with quality improvement initiatives will significantly decrease the occurrence of pharmacologic errors in the NICU setting. 

Does each hospital and NICU fulfill these requirements? (I recommend you also read my article on hospitals’ responsibilities).

When a neonatal chart reviewer identifies unfavorable outcomes in a baby due to a medication error, reviewing pertinent hospital policies and treatment protocols, checking staffing levels, and inquiring about electronic medical records and infusion pump software versions may be necessary.