Strategies For Decreasing Medication Errors in the Neonatal Intensive Care Unit

Strategies For Decreasing Medication Errors in the Neonatal Intensive Care Unit is an important duty for the Registered Nurse. The possibility of serious consequences due to medication errors makes it one of the most important skills to master. Neonates, in particular, are very vulnerable to medication errors. Their size, quickly changing weight, the number of medications they receive, lack of neonate specific dosing, and off label use of medications (prescribed outside the terms of the product ldition, neonates are less able to tolerate medication errors, as R. Kaushal noted in his 2001 study, which found neonates three times as likely to have an adverse drug effect due to drug error than the general population. Nurses can reduce medication errors in the neonatal intensive care unit by using unit specific strategies, such as improved access to specific information, simplification/standardization, and reduced reliance on memory ( Lucas, 2003).
The most common medication errors in the neonatal intensive care unit are associated with dose. Statistics vary substantially between studies, partly due to differences in definition of an error and the rigor of the method used to identify medication errors (Chedoe, 2007). The rate of medication errors in the neonatal intensive care unit has been reported as high as 5.5 errors per one hundred prescriptions (Kaushal, 2001). Dose errors most frequently occur because of incorrect recording of weight, incorrect recording of the dosage regimen, incorrect units, and misplacement of the decimal point with calculating the dose (Lefrak, 2002). On average, more calculations and dilutions are involved prior to the administration of medications to neonates than compared with adults (Chedoe, 2007). Another factor contributing to medication errors in the neonatal intensive care unit is a high “off label” use of medications (Lefrak, 2002).
One technique for significantly decreasing the likelihood of medication dose errors is improving access to specific information by using of emergency medication sheets at the front of each neonate’s chart. Upon admission, each neonate receives an individualized computer generated emergency sheet. The pharmacy generates the sheets and the nurse verifies the patient weight used for the calculations. Due to rapid weight changes in the neonate population, these sheets are updated weekly. The sheets are placed at the front of the chart for easy access. The first page of the medication sheet lists the four medications needed in the event of cardiac arrest in the neonate population (epinephrine, naloxone, sodium bicarbonate, and a volume expander), with specific doses for each neonate based on their current weight (Lucas, 2003). The remainder of the sheet lists medications potentially needed in other emergencies, with the appropriate dose calculated by computer, based on the neonate’s weight.
Another strategy for reducing medication errors is standardization, such as stocking standardized concentrations of a medication on the unit (Lefrak, 2002). One study, done by Chappell and Newman in 2001, indicated 31% of the prescriptions written for a particular neonate intensive care unit had the potential for 10 fold overdoses (Chedoe, 2007). Standardization is extremely important with many medications, such as heparin, which can come in strengths ranging from ten units per millimeter to ten thousand units per millimeter. If more than one concentration is required, they should be stocked in separate places, with distinctly different labels, to decrease the likelihood of error. To further decrease the likelihood of concentration errors, drug dose, not volume, should be specified in every order (i.e. total milligrams of medication to be given, not milliliters of a specific concentration).
Reducing reliance on memory to decrease the likelihood of miscalculations in medication dosage is a third strategy for reducing medication errors. The American Society of Health-Systems Pharmacists has identified nine categories of medication errors, three of which involve medication calculation (Rice, 2005). In fact, researchers have found that more than one in six medication errors involve miscalculations (Greenfield, 2006). In the neonatal intensive care unit, the number of calculations is high, leading to a greater opportunity for error. The medication order should include specific data for calculation, such as the neonate’s weight and dose per unit weight. This provides sufficient information for the pharmacist preparing the medication, and the nurse administering it, to recalculate the dose as a second, and even third check (Lucas, 2003). Referred to as “built in redundancies”, a multiple step process that requires at least two separate calculations can significantly cut down on calculation errors. A clearly written order, which does not use abbreviations and does use leading zeros and clear decimal points, will also contribute to a decrease in the number of calculation errors (. Lefrak, 2002). Access to standard formulas for medication dosage calculations, easy to reference during medication preparation, allows a nurse to double check her mathematical concepts for formulas used less often. This is an important component given that two studies involving baccalaureate nursing students indicated that 68%-91% of their calculation errors were found to be conceptual (Rice, 2005).
Neonatal intensive care nursing is a highly skilled specialty and it is essential that nurses use all the tools available to them to ensure the safety of medication administration. Improved access to specific information, simplification/standardization, and reduced reliance on memory are three strategies that can be used to ensure neonates get the quality of care they need and deserve.
________
Intervention: Improving access to specific information by using emergency medication sheets.
Disadvantage #1: The key to this intervention is acquiring and recording an accurate weight for each patient, so the pharmacist can calculate each medication sheet. Weights recorded in differing units, such as grams versus kilograms could cause confusion and lead to erroneous dosage calculations (Levine, 2003). Weights in neonates vary widely, while dose ranges by weight are very small. It is more difficult to recognize inappropriate medication orders and there is a smaller margin of safety. Because of the large variations in doses, an overdose that would be obvious in an adult patient may go unnoticed in a neonate (Lucas, 2004).
Disadvantage #2: Medication sheets are reviewed and renewed at least weekly for each patient, as weights change quickly in the neonate population. This intervention can be time consuming for the pharmacy (Koppel, 2005), and the financial cost can be high (Levine, 2003). A technician may also be required to provide a double check (Levine, 2003). The additional staff and training could be a financial burden for the hospital, which would ultimately be borne by the patient.
Intervention: Stocking standardized concentrations of medications.
Disadvantage #1: Stocking standardized concentrations of medications can make it difficult to administer the prescribed dose without causing fluid overload in some neonates. Neonatal fluid requirements vary depending on the level of maturity and the clinical diagnosis of the patient. Some neonates, especially those born prematurely, are fluid sensitive and may require administration of highly concentrated solutions (Hennessey, 2007). In addition, patients may be hypoglycemic or hyperglycemic and require different solution bases for medication delivery (Hennessey, 2007).
Disadvantage #2: Standard concentrations make using “The Rule of Six”, a routine method for calculating continuous infusions in pediatric patients, impossible. The rule of six is a mathematical equation that calculates the amount of drug (in milligrams) to be added to 100mL of fluid so that 1mL/hr delivers the drug at a rate of 1μg/kmin. This methodStrategies For Decreasing Medication Errors in the Neonatal Intensive Care Unit
Dispensing medications is an important duty for the Registered Nurse. The possibility of serious consequences due to medication errors makes it one of the most important skills to master. Neonates, in particular, are very vulnerable to medication errors. Their size, quickly changing weight, the number of medications they receive, lack of neonate specific dosing, and off label use of medications (prescribed outside the terms of the product license) contributes to the problem. In addition, neonates are less able to tolerate medication errors, as R. Kaushal noted in his 2001 study, which found neonates three times as likely to have an adverse drug effect due to drug error than the general population. Nurses can reduce medication errors in the neonatal intensive care unit by using unit specific strategies, such as improved access to specific information, simplification/standardization, and reduced reliance on memory ( Lucas, 2003).
The most common medication errors in the neonatal intensive care unit are associated with dose. Statistics vary substantially between studies, partly due to differences in definition of an error and the rigor of the method used to identify medication errors (Chedoe, 2007). The rate of medication errors in the neonatal intensive care unit has been reported as high as 5.5 errors per one hundred prescriptions (Kaushal, 2001). Dose errors most frequently occur because of incorrect recording of weight, incorrect recording of the dosage regimen, incorrect units, and misplacement of the decimal point with calculating the dose (Lefrak, 2002). On average, more calculations and dilutions are involved prior to the administration of medications to neonates than compared with adults (Chedoe, 2007). Another factor contributing to medication errors in the neonatal intensive care unit is a high “off label” use of medications (Lefrak, 2002).
One technique for significantly decreasing the likelihood of medication dose errors is improving access to specific information by using of emergency medication sheets at the front of each neonate’s chart. Upon admission, each neonate receives an individualized computer generated emergency sheet. The pharmacy generates the sheets and the nurse verifies the patient weight used for the calculations. Due to rapid weight changes in the neonate population, these sheets are updated weekly. The sheets are placed at the front of the chart for easy access. The first page of the medication sheet lists the four medications needed in the event of cardiac arrest in the neonate population (epinephrine, naloxone, sodium bicarbonate, and a volume expander), with specific doses for each neonate based on their current weight (Lucas, 2003). The remainder of the sheet lists medications potentially needed in other emergencies, with the appropriate dose calculated by computer, based on the neonate’s weight.
Another strategy for reducing medication errors is standardization, such as stocking standardized concentrations of a medication on the unit (Lefrak, 2002). One study, done by Chappell and Newman in 2001, indicated 31% of the prescriptions written for a particular neonate intensive care unit had the potential for 10 fold overdoses (Chedoe, 2007). Standardization is extremely important with many medications, such as heparin, which can come in strengths ranging from ten units per millimeter to ten thousand units per millimeter. If more than one concentration is required, they should be stocked in separate places, with distinctly different labels, to decrease the likelihood of error. To further decrease the likelihood of concentration errors, drug dose, not volume, should be specified in every order (i.e. total milligrams of medication to be given, not milliliters of a specific concentration).
Reducing reliance on memory to decrease the likelihood of miscalculations in medication dosage is a third strategy for reducing medication errors. The American Society of Health-Systems Pharmacists has identified nine categories of medication errors, three of which involve medication calculation (Rice, 2005). In fact, researchers have found that more than one in six medication errors involve miscalculations (Greenfield, 2006). In the neonatal intensive care unit, the number of calculations is high, leading to a greater opportunity for error. The medication order should include specific data for calculation, such as the neonate’s weight and dose per unit weight. This provides sufficient information for the pharmacist preparing the medication, and the nurse administering it, to recalculate the dose as a second, and even third check (Lucas, 2003). Referred to as “built in redundancies”, a multiple step process that requires at least two separate calculations can significantly cut down on calculation errors. A clearly written order, which does not use abbreviations and does use leading zeros and clear decimal points, will also contribute to a decrease in the number of calculation errors (. Lefrak, 2002). Access to standard formulas for medication dosage calculations, easy to reference during medication preparation, allows a nurse to double check her mathematical concepts for formulas used less often. This is an important component given that two studies involving baccalaureate nursing students indicated that 68%-91% of their calculation errors were found to be conceptual (Rice, 2005).
Neonatal intensive care nursing is a highly skilled specialty and it is essential that nurses use all the tools available to them to ensure the safety of medication administration. Improved access to specific information, simplification/standardization, and reduced reliance on memory are three strategies that can be used to ensure neonates get the quality of care they need and deserve.
________
Intervention: Improving access to specific information by using emergency medication sheets.
Disadvantage #1: The key to this intervention is acquiring and recording an accurate weight for each patient, so the pharmacist can calculate each medication sheet. Weights recorded in differing units, such as grams versus kilograms could cause confusion and lead to erroneous dosage calculations (Levine, 2003). Weights in neonates vary widely, while dose ranges by weight are very small. It is more difficult to recognize inappropriate medication orders and there is a smaller margin of safety. Because of the large variations in doses, an overdose that would be obvious in an adult patient may go unnoticed in a neonate (Lucas, 2004).
Disadvantage #2: Medication sheets are reviewed and renewed at least weekly for each patient, as weights change quickly in the neonate population. This intervention can be time consuming for the pharmacy (Koppel, 2005), and the financial cost can be high (Levine, 2003). A technician may also be required to provide a double check (Levine, 2003). The additional staff and training could be a financial burden for the hospital, which would ultimately be borne by the patient.
Intervention: Stocking standardized concentrations of medications.
Disadvantage #1: Stocking standardized concentrations of medications can make it difficult to administer the prescribed dose without causing fluid overload in some neonates. Neonatal fluid requirements vary depending on the level of maturity and the clinical diagnosis of the patient. Some neonates, especially those born prematurely, are fluid sensitive and may require administration of highly concentrated solutions (Hennessey, 2007). In addition, patients may be hypoglycemic or hyperglycemic and require different solution bases for medication delivery (Hennessey, 2007).
Disadvantage #2: Standard concentrations make using “The Rule of Six”, a routine method for calculating continuous infusions in pediatric patients, impossible. The rule of six is a mathematical equation that calculates the amount of drug (in milligrams) to be added to 100mL of fluid so that 1mL/hr delivers the drug at a rate of 1μg/kg/min. This method results in patient specific drug concentrations (Hennessey, 2007). Having only one concentration of a particular medication available precludes using this method.
References:
Hennessy, S. Developing standard concentrations in the neonatal intensive care unit. American Jounral of health System Pharmacy 2007 64(1) 28-30. Retrieved May 5, 2008 from Google.
Koppel, R., Metlay, J., Cohen, A. Role of computerized physician order entry systems in
facilitating medication errors. The Journal of the American Medical Association 2005 293(10) 1197-1203. Retrieved May 5, 2008 from Google
Levine, S., Holbrook, K. Medication safety in the pediatric emergency department.
Hospital Pharmacy 2003: 38(5) 426-435. Retrieved May 5, 2008 from Google.
Lucas, Amber. Improving medication safety in a neonatal intensive care unit. American
Journal of Health System Pharmacy 2004 61(1) 33-37. Retrieved May 5, 2008 from Google.
in patient specific drug concentrations (Hennessey, 2007). Having only one concentration of a particular medication available precludes using this method.
References:
Hennessy, S. Developing standard concentrations in the neonatal intensive care unit. American Jounral of health System Pharmacy 2007 64(1) 28-30. Retrieved May 5, 2008 from Google.
Koppel, R., Metlay, J., Cohen, A. Role of computerized physician order entry systems in
facilitating medication errors. The Journal of the American Medical Association 2005 293(10) 1197-1203. Retrieved May 5, 2008 from Google
Levine, S., Holbrook, K. Medication safety in the pediatric emergency department.
Hospital Pharmacy 2003: 38(5) 426-435. Retrieved May 5, 2008 from Google.
Lucas, Amber. Improving medication safety in a neonatal intensive care unit. American
Journal of Health System Pharmacy 2004 61(1) 33-37. Retrieved May 5, 2008 from Google.