Medication errors (MEs) represent approximately one-third of all errors in medical care.1 In this regard, it is also estimated that one-third of all MEs in pediatrics and neonatal care occur in the course of medication preparation and administration, and that 18.7% to 56.0% of all adverse events among hospitalized patients are attributable to avoidable MEs.2

The administration of medications in clinical practice is a complex process with multiple possibilities of error.3 The intensive care setting is characterized by frequent handling of drugs, and thus stands out in this respect.

Medication errors are frequent in neonates,4–6 since these patients are vulnerable due to many factors such as physiological immaturity and rapid changes in body weight that affect the dosing of medications based on patient weight.7,8

Medication error can occur in any of the phases of drug use: selection and management, prescription, validation, preparation, dispensation, administration and follow-up. The administration of drugs is normally carried out by nurses based on a specific “5 correct” items protocol (correct patient, drug, dose, time and administration route).9 Many factors can have a negative impact on this process, such as simultaneous demands and interruptions, omissions in procedure, lack of clinical experience, and factors related to the system.10,11 Different studies have confirmed that errors recorded during drug administration can be avoided, thus highlighting the important role played by nursing professionals in the system for promoting patient safety.

The present systematic review was carried out to describe the most current evidence on MEs in neonatal intensive care.

Eight studies that met the inclusion criteria were carefully reviewed. Most of the studies were carried out in Brazil. The publication dates of the included articles were between 2019 and 2023. The study sample sizes in turn ranged between 24 and 133,000 participants. The characteristics of each included article are shown in Table 1.

It is important to consider and analyze MEs in neonatal intensive care. Three studies15–17 analyzed healthcare technologies involving intelligent infusion pumps and their effectiveness. Two studies18,19 performed cost-effectiveness analyses of medications in the reduction of dosing errors. Another two articles articles20,21 examined healthcare professional practice in the administration of medications. One study22 analyzed the appearance of ME and determined the efficacy of a quality improvement model.

Melton et al.15 found that the nursing staff correctly used intelligent pumps and programmed most infusions using the medications guide with a dosage error reduction software application. As in other studies, such a high compliance rate was found to be crucial for the effective use of intelligent pumps.23

Felipe et al.16 reported an association between the performance of the syringe infusion pump, the type of solution infused, and the height at which the device was positioned. The most important risk factors associated with the clinical use of syringe infusion pumps include overdose or an insufficient dose as a result of imprecision in the amount of medication infused, leading to adverse events such as oversedation, respiratory depression, or significant blood pressure fluctuations.24 The incidence rate of errors of this kind is particularly important in the neonatal population since these patients require more precise doses and low infusion volumes.25 However, as seen in this study, syringe infusion pumps lost precision when a low infusion rate was established, and an extreme 20.1% incidence of errors was recorded in evaluating the total infused volume.

Silva et al.17 found that infusion pumps with a drug library imply greater cost but also afford greater effectiveness. Some studies have obtained inconclusive results regarding the effectiveness of intelligent pumps in reducing adverse drug reactions, reporting that there is no reduction of the risk associated with the implantation of intelligent pumps,26 though other studies have concluded that this technology can avoid dosing errors and thus increase patient safety.27

The cost-effectiveness analysis published by Kriz et al.18 showed that even a modest 10% increase in the use of ready-to-use three-chamber bags in premature infants receiving parenteral nutrition could substantially improve the clinical outcomes, reduce work time, and lessen the impact on hospital budgets. It is important to note that the incidences of significant and severe damage due to composite errors could decrease markedly between 10–13%, and the sepsis rate between 2–3%. As in other studies, the risk of infection can be reduced directly by limiting the number of manipulation steps involved.28

The results of Marques et al.19 should alert nursing professionals and healthcare management bodies to reconsider the use of traditional methods for the preparation of intravenous medications since they question the preparation of drugs for injection by nursing teams. In this sense, the American Society of Health-System Pharmacists points to the distribution of single-dose formulations and the use of the pharmacy intravenous drug preparation system as important recommendations for preventing MEs in a hospital. Studies conducted by the Instituto da Criança showed that with the availability of single-dose formulations, pharmacies can reduce internal consumption by up to 35%.29 In the case of premature infants, implementation of the intravenous drugs mixture unit affords greater treatment safety and quality.30

Manzo et al.20 underscored that the unique characteristics and complexity of therapy in neonatology make it extremely important to continuously increase scientific knowledge and capacitation in this field.31 However, this study found that 63.9% of the participants reported not having participated in courses or conferences on the preparation and administration of drugs in the last year, and that most had doubts regarding the action of medications. Thus, in order to ensure safety and quality, it is necessary to revise the working processes based on the scientific evidence, and to make sure that the professionals (both leaders and those under their supervision) are capacitated and duly qualified.

Sassaki et al.21 highlighted the preparation phase as being critical for interruptions among the nursing staff (48%) and nursing technicians (28.3%), in concordance with the observations of another study (72.7%).32 It must be mentioned that when the professional is interrupted, his or her attention focuses on other demands,33 and such distractions account for almost 50% of all MEs.34

In the study published by Mondal, et al.,22 a considerable number of errors were related to incorrect timings or intervals. A South African study also found the most common problem to be an incorrect drug prescription interval, associated mainly with antibiotic prescription, since the interval of certain antibiotics varies according to the age of the newborn.35 Although the different error indicators in this study were not significantly correlated to the gestational age of the neonates, other studies have pointed to prematurity as a significant determinant in the appearance of MEs, possibly due to longer hospital stays or the use of more medications or complex calculations as causal factors.36

Observational,20,21 experimental16,22 and cost analysis18,19 studies were the most widely used designs. Among the different articles, healthcare technology analyses and cost-effectiveness and practice studies referred to MEs in neonatal intensive care were the main topics. At a practical level, mention should be made of the observation that decision-making regarding the incorporation of technologies could reduce dosage errors in the administration of medications in neonatal intensive care.

The 8 reviewed studies involved different interventions and different outcome measures – a fact that complicates the drawing of conclusions as to which intervention is most effective. Future research on this subject should take into account the aspects highlighted by the World Health Organization (WHO) to secure safer patient care, seeking causes, proposing solutions, and evaluating impacts. We thus advise the conduction of multicenter studies using the same measurement tools to determine the effectiveness of interventions in terms of specific outcomes.

The present review has several limitations. Because of the observed methodological heterogeneity, the characteristics of the participants and the representativeness of the studies, it is difficult to draw conclusions and generalize the findings to other contexts. Lastly, although extensive database and manual searches were made, some relevant studies inadvertently might have been excluded.

The present systematic review provides information on the current evidence on the analysis of MEs in neonatal intensive care. The implications of the findings for patient safety refer to the need to apply healthcare technology (intelligent pumps) and new models of quality improvement, as well as improvements in the administration of medications on the part of the nursing staff. In this sense, the study could be a useful tool for promoting treatment safety and quality in neonatal intensive care.

In addition, further studies are needed, with the adoption of strategies by the healthcare administrations/organizations in neonatal intensive care, including the analysis of their applicability in different contexts.

None.

F.M.E.R: Conceptualization, supervision, review and editing of the text. L.P.F: Data search, draft preparation and synthesis. All signing authors reviewed the manuscript, made relevant contributions, and agreed to the final version.

None.