TITLE

Origins of and solutions for neonatal medication-dispensing errors

AUTHOR(S)
Sauberan, Jason B.; Dean, Linda M.; Fiedelak, Jessica; Abraham, Julie A.
PUB. DATE
January 2010
SOURCE
American Journal of Health-System Pharmacy;1/1/2010, Vol. 67 Issue 1, p49
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
Purpose. Five cases of sound-alike, lookalike, neonatal medication-dispensing errors and their resolution are reviewed. Summary. In 2008, there were five cases in which look-alike or sound-alike neonatal medication-dispensing errors occurred at our institution. A mix-up between neonatal and adult or pediatric products occurred in four of the five cases. Three of the five errors resulted in near misses with the potential to cause harm. The other two errors reached the patients but did not cause harm. The medication mix-ups involved adult and neonatal phytonadione injectable emulsion, sodium citrate injection and vancomycin-heparin combination injection, adult tetanus-diphtheria-acellular pertussis and infant diphtheria-tetanus- acellular pertussis (DTaP) vaccines, Haemophilus B and DTaP vaccines, and cisatracurium and vecuronium. Each error exposed weaknesses in the system of neonatal medication storage, labeling, delivery, knowledge, and administration documentation at our institution. Resolution of system problems was made possible by a collaborative approach and involved reorganizing shelving used to store neonatal medications; using a differently colored labeling scheme for products whose syringes were nearly identical; implementing changes to the infant vaccine ordering, storage, dispensing, and documentation systems; and instituting centralized and decentralized pharmacist review of pharmacy technician automated dispensing cabinet-filling activities. Conclusion. An institution providing services to both neonatal and adult patients experienced five cases of medicationdispensing errors with look-alike or soundalike medications. Multidisciplinary collaboration within the system helped the pharmacy identify, resolve, and prevent errors related to medication storage, labeling, delivery, knowledge, and administration documentation.
ACCESSION #
47426688

 

Related Articles

  • DTaP or Tdap: Vaccine and drug name confusion. Bell, Edward // Infectious Diseases in Children;Oct2010, Vol. 23 Issue 10, p12 

    The article discusses the vaccine product confusion that has occurred with diphtheria-tetanus-acellular pertussis (DTaP) and Tdap products, and the preventive measures to take to avoid vaccine product mix-ups.

  • Assessment of Pediatrics Errors in Practice. Trninic, Slobodan // Materia Socio Medica;2009, Vol. 21 Issue 2, p95 

    INTRODUCTION. Medical errors have been defined as a major public health problem in Bosnia and Herzegovina. Children are at higher risk for medication errors and adverse drug events for numerous reasons. The objective of this study was to assess the prevalence and characteristics of medication...

  • PREVENTING DEATH by decimal point. Broselow, James; Luten, Robert; Schuman, Andrew J. // Contemporary Pediatrics;Jun2008, Vol. 25 Issue 6, p35 

    The article offers information on the causes and consequences of medication errors in young patients. One of the reasons patients are at risk for medication errors is the fact that too many drugs lack the formal licensing approval of the U.S. Food and Drug Administration (FDA) for pediatric...

  • Drug errors common in hospitals.  // Drug Topics;9/16/2002, Vol. 146 Issue 18, p8 

    Reports on a study showing the prevalence of medication errors in hospitals and other health facilities in the United States. Most frequent errors committed; Assessment of drugs dispensed in hospitals and nursing centers.

  • More hospitals report medication errors,but USP finds few changes. Young, Donna // American Journal of Health-System Pharmacy;7/1/2002, Vol. 59 Issue 13, p1233 

    Relates the causes of medication errors reported by health systems in 1999 and 2000, according to a report by the United States Pharmacopeia. Omission errors; Incorrect doses; Administration of the wrong drug products.

  • Observation method of detecting medication errors. Barker, Kenneth N.; Flynn, Elizabeth A.; Pepper, Ginette A. // American Journal of Health-System Pharmacy;12/1/2002, Vol. 59 Issue 23, p2314 

    Discusses various aspects of the observation method in detecting medication errors. History; Advantages; Comparison with other methods; Modification of the observation method.

  • A Worthwhile Accompaniment.  // People's Medical Society Newsletter;Oct99, Vol. 18 Issue 5, p5 

    Reports that Harvard University researchers have discovered a simple, cost-effective way to reduce hospital medication errors.

  • How to avoid taking wrong medicines.  // Westchester County Business Journal;11/25/2002, Vol. 41 Issue 47, p20 

    Discusses strategies for patients to prevent taking wrong medication. Questions to ask to ensure the right drugs are taken; Vigilance in the process of ordering, transcribing and dispensing drugs.

  • Medi-Dose/EPS partners with Emily Jerry Foundation for pediatric safety initiative.  // DVM: The Newsmagazine of Veterinary Medicine;Apr2013, Vol. 44 Issue 4, p74 

    The article reports that Medi-Dose/EPS is working with the Emily Jerry Foundation for pediatric patients safety initiative.

Share

Read the Article

Courtesy of VIRGINIA BEACH PUBLIC LIBRARY AND SYSTEM

Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics