Article Text

Download PDFPDF
PS-016 Medication safety in neonatal care: analysis of high alert medications
  1. M Moro,
  2. M Freire,
  3. C Sobrino,
  4. MJ De Domingo,
  5. A Herrero
  1. La Paz University Hospital, Hospital Pharmacy, Madrid, Spain


Background Medication errors are common in neonatal units. Errors with potential to cause harm are more likely to occur here due to vulnerability of this population and the complexity of calculations for prescribing and preparing their medications. Errors with high alert medications (HAM) in neonatal units have been reported. These errors bear a heightened risk of causing significant patient harm. The incidence of errors is variable among studies. Having knowledge of your own HAM utilisation rate could help organisations to prioritise safe medication practices.

Purpose To analyse the use of HAM in a neonatal unit as a tool to prioritise patient safety practices.

Material and methods An observational retrospective study was conducted in 2015 (12 months) in the neonatal unit of a university tertiary hospital. Recorded data of admissions, hospital stays and HAM consumption were analysed. The classification of HAM was according to the ISMP list and high risk drug list adapted to the neonatal or paediatric population (Cotrina et al, 2013).

Results During the study period 1470 admissions and 21 611 stays were registered (14.7 stays per patient). A total of 311 different drugs were used, 23.2% (n=72) were HAM, 11 of these HAM (15.3%) being exclusively on the paediatrics list. 214 607 units were consumed, 11% were HAM (n=23 550). The main HAM detected were: antithrombotics/anticoagulants/heparins (20%), sterile water 500 mL (19%), acetaminophen (13%), general anaesthetics (11%, mainly fentanyl), antibiotics (10%, mainly vancomycin), adrenergic agonists (7%), adrenergic antagonists (3%), opioids (3%), hypertonic glucose (3%) and antiepileptic drugs (3%). The remaining 8% corresponded to: antihypertensives, neuromuscular blocking agents, inotropics, sedatives, electrolytes, antiarrhythmics and insulin. All of these drugs are frequently involved in published medication errors. General safe practices were already implemented in our hospital: protocols, training sessions and courses, summary charts for drug preparation, a dose calculator and a patient safety multidisciplinary group. Specific additional safe practices should be implemented for the HAM most frequently used.

Conclusion Specific strategies in the safe use of antithrombotics, anticoagulants and heparins, sterile water, acetaminophen, fentanyl and vancomycin must be implemented. This is critical in neonatal units, where the use of these HAM is more common and the risk of harm is higher.

References and/or acknowledgements An Pediatr (Barc)2013;79:360–6.

No conflict of interest

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.