Errors of intravenous (IV) fluid and drug administration are common. Reporting of such is important, but should never be made the pretext for disciplinary action unless there has been obvious negligence. The prescriber shares responsibility for any administrative error that occurs when prescribing in an unclear or unnecessarily complex way. Staff new in place, at all levels, frequently find themselves working under considerable pressure, and low staffing levels often impose further stress. Management share responsibility for protecting staff from excessive pressure, for ensuring that unit policies are such as to minimise the risk of any error occurring and (even more importantly) for seeing that the potential danger associated with any error is minimised by the use of ‘fail-safe’ routines like those outlined below. If senior staff and managers over-react when mistakes occur, errors may simply go unreported, increasing the risk of a recurrence.

It is important to retain a sense of proportion in considering the issues raised by the rule that every error of drug prescribing has to be reported. While any error of commission is generally looked upon as a potentially serious disciplinary issue, serious errors of omission often go unremarked. Inadvertent reductions in IV fluid administration due to tissue extravasation, failure to resite an infusion line promptly or failure to set up the syringe pump correctly, are more likely to put a baby at hazard (from reactive hypoglycaemia) than a transient period of excess fluid administration. Note that hypoglycaemia is particularly likely to occur where a maintenance infusion of glucose saline IV is cut back or stopped abruptly so that blood can be given (for guidance on this, see the monograph on blood transfusion). Similarly, failure to give a dose of medicine may sometimes be just as hazardous as the administration of too big a dose.

Drug prescribing and drug administration call for close teamwork between the medical, midwifery and nursing staff. When an error does occur it is seldom one person’s sole fault, and this needs to be acknowledged if disciplinary action is called for. Where it is clear that a doctor and a midwife or nurse both share responsibility for any untoward incident, natural justice demands that any necessary disciplinary action is handled in an equable and equitable way.

Minor medication errors (i.e. any deviation from the doctor’s order as written on the patient’s hospital chart) are extremely common. Rates of between one per patient day and two per patient week have been reported in the United States. Prescribing errors are also common. Anonymous self-reporting schemes have been initiated in a few hospitals, as part of a more general risk management strategy, in an attempt to identify high risk situations. Dilutional errors are particularly common in neonatal practice, and the individual drug guidelines in this compendium have been carefully framed so as to minimise these.

Ten golden rules

Attention to the following 10 rules will help to minimise error and, even more importantly, ensure that when an error does occur the impact is minimised:

1. Keep the prescribing of medication to a minimum, and use once or twice daily administration where this is possible.
   
2. Never have more than two IV infusion lines running at the same time unless this is absolutely necessary.
   
3. Never put more than 30 ml of fluid at any one time into any syringe used to provide continuous IV fluid or milk for a baby weighing less than 1 kg.
   
4. Record the amount of fluid administered by every syringe pump by inspecting the movement of the syringe and by inspecting the infusion site once every hour. Do not rely merely on any digital electronic display.
   
5. In an analogous way, where the infusion of fluid from any large (half litre) reservoir is controlled by a peristaltic pump (or by a gravity operated system with a gate valve and drop counter), it is always wise to interpose a burette between the main reservoir and the control unit. Limiting the amount of fluid in the burette limits the risk of accidental fluid overload, and recording the amount of fluid left in the burette every hour speeds the recognition of any administrative error.
   
6. Do not change the feeding or IV fluid regime more than once or, at most, twice a day except for a very good reason. Try to arrange that such changes as do have to be made are made during the morning or evening joint management rounds.
   
7. Those few drugs that have to be administered over 30 minutes or more should be administered using a separate programmable syringe pump ‘piggy-backed’ onto an existing IV Line. As an extra precaution, the syringe should never be set up containing more than twice as much of the drug as it is planned to deliver. Do not adjust the rate at which the main IV infusion fluid is administered unless there is a serious risk of hyperglycaemia, or it is necessary to place an absolute restriction on the total daily fluid intake.
   
8. Do not routinely flush drugs or fluids through an established IV line except in the rare situations where this is specifically recommended in this compendium. To do so can expose the baby to a dangerously abrupt ‘bolus’ of drug. Using fluid from the main IV line to do this can also make the baby briefly and abruptly hyperglycaemic.
   
9. Beware giving a small newborn baby excess sodium unintentionally. The use of flush solutions of Hep-lok®, Hepsal® or 0.9% sodium chloride can expose a baby to an unintended excess of IV sodium. The steady infusion of 1 ml/hour of heparinised 0.9% sodium chloride (normal saline) to maintain catheter patency is sometimes enough to double a very small baby’s total daily sodium intake. So too can intra-tracheal sodium chloride administration during tracheal ‘toilet’.
   
10. Treat the prescribing of potentially toxic or lethal drugs (such as chloramphenicol and digoxin) with special care. There are relatively few situations where it is really necessary to use such potentially dangerous drugs.