Elsami et al identified risk factors for medication errors in a neonatal intensive care unit (NICU). The authors are from Imam Khomeini Hospital and Ahvaz Jundishapur Unversity in Iran.

Patient selection: patient in a neonatal ICU


Common problems:

(1) wrong dosage

(2) failure to administer a medication

(3) wrong route of administration

(4) wrong dosing interval

(5) lack of time and/or date of order


Risk factors for errors:

(1) preterm neonate (gestational age < 37 weeks; OR 21.6 for wrong dose)

(2) manual ordering systems (lack of computerized physician order entry)

(3) low nurse-to-patient ratio


Additional factors:

(1) age at admission < 7 days

(2) hospital length of stay < 7 days


It is also important to ensure positive identification of the patient prior to administering a dose.

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