More neonatal error report studies needed
More studies of incident reporting systems in neonatal intensive care are needed. Those studies that are available, and which evaluate the impact of preventive strategies, suggest that pharmacist-led review of drug orders prevents errors. These are among the conclusions from a systematic review of papers about incident reporting systems in neonatal intensive care, published online in Archives of Disease in Childhood (available
at www.archdischild.com).
From a database search, researchers found 10 prospective or retrospective
studies that matched their inclusion criteria, but no randomised controlled
trials or other systematic reviews.
They found that most incident reporting systems used a non-punitive,
anonymous, voluntary approach to incidents. Although this generates more
reports, a drawback is that people cannot be contacted for further details
about events.
Medication errors were the most frequently reported type of incident,
with contributory factors including poor communication and failure to
follow procedures. Few fatal or potentially fatal drug errors were reported.
Preventative strategies suggested (in addition to pharmacist-led review)
included introducing standardised prescription forms and electronic prescribing
with clinical decision support.
|
Hospital
Pharmacist