Abstract
Background and aims: Since the onset of incident reporting, medication errors have been noted to be one of the most common reasons for reporting a clinical incident and antibiotics have been shown to be one of the most common drugs associated with medication error in children. This trend was also noted in the neonatology department in Craigavon Area Hospital, a busy district general hospital with 3900 deliveries per year. The aim is to evaluate whether the introduction of a gentamicin prescription, administration and monitoring chart reduces the number of medication errors.
Methods: A retrospective audit looking at all the reported clinical incidents forms involving gentamicin over a 7 year period between 2002 and 2008.
Results: Since the introduction of the new chart in 2005 there was a 16% (0.75) reduction in the average annual number of medication errors involving gentamicin from 4.75 to 4.00. There were no further incidents recorded where the wrong dose of gentamicin was given or where a dose was given despite a high serum concentration. There has also been a 67% reduction in incidents where a gentamicin level was not monitored as required.
Conclusions: There has been some improvement in the number of gentamicin-based clinical incidents with the introduction of a gentamicin-specific chart, however errors are still occurring. Recommendations include the introduction of regular training on appropriate gentamicin prescribing for new staff and a mandatory yearly update for permanent staff. There is a plan to re-audit this yearly, with consideration of electronic prescribing.
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Flannigan, C., Kilpatrick, S., Redpath, J. et al. 481 Can a Gentamicin Specific Chart Reduce Neonatal Medication Errors?. Pediatr Res 68 (Suppl 1), 245–246 (2010). https://doi.org/10.1203/00006450-201011001-00481
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DOI: https://doi.org/10.1203/00006450-201011001-00481