High-alert medication administration errors in a neonatal unit

Abstract

Medication errors (MEs) are a frequent and preventable cause of harm, with a high clinical and economic impact, especially when they involve high-alert medications (HAMs). These drugs are generally used in hospitalized neonates, who, due to their physiological immaturity, are at higher risk of suffering from MEs.

Objective: To analyze MEs during the intravenous administration of HAMs in a neonatal critical care unit.

Patients and Method: Cross-sectional, retrospective study conducted in a neonatal critical care unit of a high-complexity public hospital. Reports of MEs during intravenous administration of HAMs in hospitalized newborns between 2020 and 2024 were included. Records with incomplete information were excluded. Results are presented using absolute and relative frequencies, median, and interquartile range (IQR: p25–p75).

Results: A total of 34 MEs were reported, 15/34 (44%) involved HAMs in patients with a median gestational age of 30.0 weeks (IQR: 26.3–36.3); and a median hospital stay of 9 days (IQR: 6.0–21.0). In 5/15 (33%) cases, it was due to wrong infusion rate, lack of care, and misuse of infusion pumps; 10/15 (67%) of MEs did not harm the patient, and 13/15 (87%) were reported by nursing staff. The most frequent HAMs were parenteral nutrition 5/15 (33%) and adrenergic agonists 5/15 (33%).

Conclusions: MEs included essential HAMs in intensive care units, whose intravenous infusion was compromised by inappropriate rates attributed to human factors. Thus, it is necessary to strengthen the culture of safety, implement rigorous protocols, and promote ongoing training of the healthcare team, especially in the use of technologies.