Background

Drug errors are an avoidable cause of iatrogenic injury in neonatal patients. Most (71%) medication errors are due to poor prescribing. The most common example of this in many studies is an incorrect dose (unexplained deviation of >10% from the neonatal unit formulary) or an incorrect dose interval; this is something particularly seen with gentamicin and vancomycin. To counter this particular aspect, many units now employ a ‘gentamicin safety bundle’, and there are similar ones for vancomycin (see below).

Dosing errors may also become a factor when staff are making up individualised infusion – more common in neonatal and paediatric practice than in adults because of many different factors such as changes in weight over the course of a neonatal stay and age-related maturational changes in drug pharmacokinetics and pharmacodynamics. Many infusions are, out of necessity, made up after undertaking sometimes complex calculations and dilutions that have the potential for errors in the placing of decimal points leading to × 10 dosing errors. Standardising the composition of the infusion and using a ‘constant concentration variable rate’ method of administration often in conjunction with Intelligent Infusion Pump Systems (sometimes referred to as Smart Pumps) may take away a lot of the cot-side calculation that currently occurs.

The similarity of some drug names can cause the wrong medication to be administered, particularly if the prescription is also barely legible. In North America, one initiative that has been introduced to counter this is the ‘Tall man’ system of writing drug names. This uses a mix of UPPERCASE and lowercase letters in the name of the medication such that it becomes easier to see differences between drug names that would otherwise look very similar.

Gentamicin bundle

In 2010, the National Patient Safety Agency (NPSA) developed a Patient Safety Alert around a care bundle for the safer use of IV gentamicin for neonates. Data collected by the NPSA had shown that 15% of all neonatal medication errors involved the prescription, administration and monitoring of gentamicin. A number of factors were implicated in these errors including:

1. Medication error
   
2. Interruptions and distractions to those involved in drug administration
   
3. Incorrectly calculating doses
   
4. Incorrectly calculating dosing intervals – especially a problem when the dose interval is 36 hours (as can be the case in neonates)
   
5. Lack of any double-checking by staff preparing and administering the drugs
   
6. Training, education and communication

The resulting neonatal gentamicin care bundle incorporates the following four elements:

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