Table 2 Summary of the medication errors that occurred in neonatal intensive care units that were experienced by the interviewees
# | Category | Medication errors |
|---|---|---|
| Â | 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 | |
| Â | 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 10Â min when administration for 30Â 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 10Â mg morphine when 1Â 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 3Â h instead of every 6Â h or every 6Â h instead of every 3Â 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 | |
| Â | 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) | |