Article Text

Download PDFPDF

4CPS-181 Electronic prescribing in the neonatal intensive care unit: analysis of prescribing errors and risk factors
  1. L Canales1,
  2. C García-Muñoz1,
  3. JM Caro1,
  4. M Francisco1,
  5. J Maria Del Carmen1,
  6. F Jose Miguel1,
  7. P Salvador2,
  8. P Carmen Rosa2,
  9. M Maria Teresa1
  1. 1Hospital 12 De Octubre, Servicio De Farmacia, Madrid, Spain
  2. 2Hospital 12 De Octubre, Servicio De Neonatología, Madrid, Spain


Background and Importance Patients admitted to neonatal intensive care units (NICU) are up to eight times more at risk of medication errors than patients admitted to adult intensive care units. Prescribing errors account for up to 74% of medication errors. The implementation of electronic prescribing has been postulated as a useful tool to reduce prescription errors.

Aim and Objectives To analyse the most prevalent prescribing errors with the e-prescribing system and to analyse risk factors.

Material and Methods All patients born during the study period who were admitted to the NICU for at least 24 hours and with active pharmacological treatment were included in the study. The prescriptions were made in the IntelliSpace Critical Care and Anaesthesia (ICCA®) electronic assisted prescription software integrated in the medical record for the critically ill patient. Treatment review was performed by a pharmacist on a daily basis and errors were graded according to the taxonomic criteria of the National Coordinating Council for Medication Error Reporting and Prevention.

Results 240 patients participated (September 2021 to June/2022). A total of 13,876 prescriptions were reviewed in 158 patients; 455 errors were found in 119 patients.

Prescribing errors were concentrated in 40 drugs/nutritions of the total 139 that were prescribed. The most frequent error was the discrepancy between the prescription and the associated free text field (n=96) with more than half of these errors (n=106,54.1%) concentrated in enteral nutrition. The five drugs with the most errors were: lactobacillus acidofilus (n=45,9.89%), caffeine citrate (n=40,8.79%), paracetamol (n=35,7.69%), gentamicin (n=25,5.49%) and cholecalciferol (n=16,3.52%).

In terms of risk factors, patients with a birth weight between 1000–1500 grams were 82% more likely to have an error than those with extremely low birth weight (<1000g) (OR=1.81, CI 95% 1.42–2.89, p<0.05). Prematurity was also associated with an increased risk of prescription errors, the patients at highest risk were those with gestational age between 28–32 weeks, with 29.80% higher risk of prescription error compared to gestational age less than 28 weeks (OR=1.29,CI 95% 1.02–1.65, p<0.05).

Conclusion and Relevance Prescribing errors were more frequent in very low birth weight and very preterm patients. It is important to know which drugs are more susceptible to e-prescribing errors and in which type of patients in order to implement additional safety measures.

Conflict of Interest 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.