[Intravenous drug preparation errors in a Neonatal Intensive Care Unit. A potential source of adverse events]

Abstract

Introduction: To determine the rate of errors during preparation of intravenous drugs in a regional Neonatal Intensive Care Unit (NICU).

Methods: A prospective observational study was performed on 24 non-consecutive working days. The vancomycin and tobramycin solutions administered were analysed to determine drug concentrations. We defined 2 types of error: 1) calculation error, when the deviation between the dose prescribed by the physician and theoretical dose administered, according to calculations performed by the nurse, was greater than ±10%, and 2) precision error, when the deviation between the theoretical concentration and that determined by the laboratory was greater than ±10%.

Results: A total of 91 samples were collected, 52 of vancomycin and 39 of tobramycin. Calculation errors were detected in 4.6% of samples. Precision errors were identified in 37.9% of the total sample.

Conclusions: Although the errors reported did not produce adverse clinical consequences, our findings point out a potential source of severe complications. Better methods in the preparation of intravenous medications in NICU are needed.