Reducing Medication Errors on a Busy Tertiary Neonatal Intensive Care Unit using a Quality Improvement Approach

Objectives: Due to a high rate of reported medication errors on our neonatal intensive care unit (NICU), a quality improvement project was undertaken to tackle the problem in 2015. The steps included the development of a customized formulary, which was aligned to the electronic prescribing system and the smart pump libraries. The incidence of medication errors after serial introduction of the interventions was studied. Methods: Data on medication errors were extracted from the online incident reporting system. Additional data were derived from the pharmacy database. Trend on errors for the whole year was analyzed. Results: The medication error rate fell from 25.7/1000 to 6.7/1000 patient-days with the implementation of the project which was sustained even after the project implementation was complete. There was a statistically significant reduction in the rate of medication errors over the course of the year. Conclusions: Medication errors are common in neonatal care. A quality improvement approach with enhancements of existing systems significantly reduced the reported medication errors on the local NICU.