Can a gentamicin-specific chart reduce neonatal medication errors?
Christopher Flannigan1, Sandra Kilpatrick2, Jilly Redpath2, Martina Hogan2
1Royal Jubilee Maternity Hospital, Regional Neonatal Unit, Belfast, Northern Ireland; 2Craigavon Area Hospital, Neonatal Unit, Portadown, Northern Ireland
Objective: To evaluate whether the introduction of a gentamicin prescription, administration and monitoring chart reduces the number of medication errors.
Setting: The neonatal department of a district general hospital in Northern Ireland.
Design: A retrospective audit looking at all the reported clinical incident 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.
Conclusion: 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.
Keywords: gentamicin, audit, medication errors, neonatal
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