International Journal of Clinical Pharmacy

, Volume 39, Issue 1, pp 88–94 | Cite as

A description of medication errors reported by pharmacists in a neonatal intensive care unit

  • Shane PawlukEmail author
  • Myriam Jaam
  • Fatima Hazi
  • Moza Sulaiman Al Hail
  • Wessam El Kassem
  • Hanan Khalifa
  • Binny Thomas
  • Pallivalappila Abdul Rouf
Research Article


Background Patients in the Neonatal Intensive Care Unit (NICU) are at an increased risk for medication errors. Objective The objective of this study is to describe the nature and setting of medication errors occurring in patients admitted to an NICU in Qatar based on a standard electronic system reported by pharmacists. Setting Neonatal intensive care unit, Doha, Qatar. Method This was a retrospective cross-sectional study on medication errors reported electronically by pharmacists in the NICU between January 1, 2014 and April 30, 2015. Main outcome measure Data collected included patient information, and incident details including error category, medications involved, and follow-up completed. Results A total of 201 NICU pharmacists-reported medication errors were submitted during the study period. All reported errors did not reach the patient and did not cause harm. Of the errors reported, 98.5% occurred in the prescribing phase of the medication process with 58.7% being due to calculation errors. Overall, 53 different medications were documented in error reports with the anti-infective agents being the most frequently cited. The majority of incidents indicated that the primary prescriber was contacted and the error was resolved before reaching the next phase of the medication process. Conclusion Medication errors reported by pharmacists occur most frequently in the prescribing phase of the medication process. Our data suggest that error reporting systems need to be specific to the population involved. Special attention should be paid to frequently used medications in the NICU as these were responsible for the greatest numbers of medication errors.


Medication errors Neonates Patient safety Quality assurance Qatar 



We would like to thank the pharmacists who completed medication error reports during this time.


This project was funded by Qatar University Student Grant: QUST-CPH-SPR-14/15-2.

Conflicts of interest

The authors do not have a conflict of interest to declare.


  1. 1.
    Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Institute of Medicine Committee on Quality of Healthare in America. National Academies Press (US), 2000. Accessed 3 October 2016.
  2. 2.
    Slonim AD, Lafkeur BJ, Ahmed W, Joseph JG. Hospital-reported medical errors in children. Pediatrics. 2003;111:617–21.CrossRefPubMedGoogle Scholar
  3. 3.
    Stelfox HT, Palmisani S, Scurlock C, Orav EJ, Bates DW. The “To Err is Human” report and the patient safety literature. Qual Saf Health Care. 2006;15:174–8.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Kanter DE, Turenne W, Slonim AD. Hospital-reported medical errors in premature neonates. Pediatr Crit Care Med. 2004;5:119–23.CrossRefPubMedGoogle Scholar
  5. 5.
    Kozer E, Scolnik D, Keays T, Shi K, Luk T, Koren G. Large errors in the dosing of medications for children. N Engl J Med. 2002;346:1175–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Gray JE, Goldmann DA. Medication errors in the neonatal intensive care unit: special patients, unique issues. Arch Dis Child Fetal Neonatal Ed. 2004;89:472–3.CrossRefGoogle Scholar
  7. 7.
    Stavroudis TA, Miller MR, Lehmann CU. Medication errors in neonates. Clin Perinatol. 2008;35:141–61.CrossRefPubMedGoogle Scholar
  8. 8.
    Snijders C, van Lingen RA, Klip H, Fetter WPF, van der Schaaf TW, Molendijk HA. Specialty-based voluntary incident reporting in neonatal intensive care: description of 4846 incident reports. Arch Dis Child Fetal Neonatal Ed. 2009;94:F210–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Ross L, Wallace J, Paton J, Stehenson T. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83:492–7.CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Simpson JH, Lyndh R, Grant J, Alroomi L. Reducing medication errors in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2004;89:480–2.CrossRefGoogle Scholar
  11. 11.
    Kaushal R, Bates DW, Landrigan C, Mickenna KJ, Clapp MD, Federico F, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114–20.CrossRefPubMedGoogle Scholar
  12. 12.
    Lanzillotti Lda S, Seta MH, Andrade CL, Mendes Junior WV. Adverse events and other incidents in neonatal intensive care units. Cien Saude Colet. 2015;20:937–46.CrossRefPubMedGoogle Scholar
  13. 13.
    Sharek PJ, Horbar JD, Mason W, Bisarya H, Thurm CW, Suresh G, et al. Adverse events in the neonatal intensive care unit: development, testing, and findings of an NICU-focused trigger tool to identify harm in North American NICUs. Pediatrics. 2006;118:1332–40.CrossRefPubMedGoogle Scholar
  14. 14.
    Stavroudis TA, Shore AD, Morlock L, Hicks RW, Bundy D, Miller MR. NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. J Perinatol. 2010;30:459–68.CrossRefPubMedGoogle Scholar
  15. 15.
    Suresh G, Horbar JD, Plsek P, Gray J, Edwards WH, Shiono PH, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004;113:1609–18.CrossRefPubMedGoogle Scholar
  16. 16.
    National Coordinating Council for Medication error reporting and prevention. Accessed 3 October 2016.
  17. 17.
    Chappell K, Newman C. Potential tenfold drug overdoses on a neonatal unit. Arch Dis Child Fetal Neonatal Ed. 2004;89:483–4.CrossRefGoogle Scholar
  18. 18.
    Frey B, Buettiker V, Hug MI, Waldvogel K, Gessler P, Ghelfi D, et al. Does critical incident reporting contribute to medication error prevention? Eur J Pediatr. 2002;161:594–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Van Rosse F, Maat B, Rademaker CM, Van Vught AJ, Egberts AC, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics. 2009;123:1184–90.CrossRefPubMedGoogle Scholar
  20. 20.
    Brunsveld-reinders AH, Arbous MS, De Vos R, De Jonge E. Incident and error reporting systems in intensive care: a systematic review of the literature. Int J Qual Health Care. 2016;28:2–13.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing 2016

Authors and Affiliations

  • Shane Pawluk
    • 1
    • 2
    Email author
  • Myriam Jaam
    • 1
  • Fatima Hazi
    • 1
  • Moza Sulaiman Al Hail
    • 2
  • Wessam El Kassem
    • 2
  • Hanan Khalifa
    • 2
  • Binny Thomas
    • 2
  • Pallivalappila Abdul Rouf
    • 2
  1. 1.College of PharmacyQatar UniversityDohaQatar
  2. 2.Pharmacy Department, Women’s HospitalHamad Medical CorporationDohaQatar

Personalised recommendations