Journal
ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION
Volume 97, Issue 6, Pages F449-F455Publisher
BMJ PUBLISHING GROUP
DOI: 10.1136/fetalneonatal-2011-300989
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Funding
- Netherlands association of hospital pharmacists (NVZA)
- Astra Zeneca
- Hospira
- BBraun
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Objective To examine the effect of a multifaceted educational intervention on the incidence of medication preparation and administration errors in a neonatal intensive care unit (NICU). Design Prospective study with a preintervention and postintervention measurement using direct observation. Setting NICU in a tertiary hospital in the Netherlands. Intervention A multifaceted educational intervention including teaching and self-study. Main outcome measures The incidence of medication preparation and administration errors. Clinical importance was assessed by three experts. Results The incidence of errors decreased from 49% (43-54%) (151 medications with one or more errors of 311 observations) to 31% (87 of 284) (25-36%). Preintervention, 0.3% (0-2%) medications contained severe errors, 26% (21-31%) moderate and 23% (18-28%) minor errors; postintervention, none 0% (0-2%) was severe, 23% (18-28%) moderate and 8% (5-12%) minor. A generalised estimating equations analysis provided an OR of 0.49 (0.29-0.84) for period (p=0.032), (route of administration (p=0.001), observer within period (p=0.036)). Conclusions The multifaceted educational intervention seemed to have contributed to a significant reduction of the preparation and administration error rate, but other measures are needed to improve medication safety further.
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