Development of a Neonatal Care System to Reduce Medication Errors

Abstract

Background: Neonates, particularly preterm infants, represent a highly vulnerable population at increased risk for medication errors due to immature organ systems, narrow therapeutic ranges, and the requirement for weight- and age-based dosing. Medication management in neonatal intensive care units (NICUs) frequently involves small-dose preparations, complex calculations, and multiple handoffs among healthcare professionals. Errors may occur at any stage of the medication-use process, including prescribing, preparation, dispensing, and administration, and even minor inaccuracies can result in serious adverse drug events, prolonged hospitalization, or mortality. Therefore, improving medication safety in NICUs is a critical patient safety priority and requires a system-based approach that addresses both clinical complexity and human factors influencing nursing practice.

Objective: To reduce medication administration errors in neonatal patients, targeting a category C–I error rate of less than 0.3 per 1,000 patient-days and eliminating category E errors.

Methods: This quality improvement study applied Continuous Quality Improvement (CQI) principles using Plan–Do–Study–Act (PDSA) cycles and Human Factors Engineering. A multidisciplinary team implemented a web-based neonatal drug application to support medication prescribing and administration. Additional interventions included simplification of medication guidelines, use of visual controls, expansion of medication error reporting channels, and ongoing staff education. Medication error rates were monitored using standardized severity classifications per 1,000 patient-days.

Results: Following implementation, medication errors classified as categories C–I decreased to fewer than 0.3 per 1,000 patient-days, with no category E or higher errors identified. Reporting of near-miss events increased, reflecting improved medication safety awareness and a strengthened patient safety culture among NICU nursing staff.

Conclusion: Integrating CQI methodology, Human Factors Engineering, and health information technology effectively reduced medication errors in neonatal care. System designs that support nursing workflow can enhance medication safety and promote sustainable quality improvement in NICUs.