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medical error neonate

Bryan M Corbett, Charles O'Connell, Mallory A Boutin, Nabil I Fatayerji, Charles W Sauer
BACKGROUND Methylergonovine is an ergot alkaloid used to treat post-partum hemorrhage secondary to uterine atony. Mistaking methylergonovine for vitamin K with accidental administration to the neonate is a rare iatrogenic illness occurring almost exclusively in the delivery room setting. Complications of ergot alkaloids in neonates include respiratory depression, seizures, and death. CASE REPORT A term infant was inadvertently given 0.1 mg of methylergonovine intramuscularly in the right thigh. The error was only noted when the vial of medication was scanned, after administration, identifying it as methylergonovine rather than vitamin K...
October 21, 2016: American Journal of Case Reports
Richard D Beger, Warwick Dunn, Michael A Schmidt, Steven S Gross, Jennifer A Kirwan, Marta Cascante, Lorraine Brennan, David S Wishart, Matej Oresic, Thomas Hankemeier, David I Broadhurst, Andrew N Lane, Karsten Suhre, Gabi Kastenmüller, Susan J Sumner, Ines Thiele, Oliver Fiehn, Rima Kaddurah-Daouk
INTRODUCTION BACKGROUND TO METABOLOMICS: Metabolomics is the comprehensive study of the metabolome, the repertoire of biochemicals (or small molecules) present in cells, tissues, and body fluids. The study of metabolism at the global or "-omics" level is a rapidly growing field that has the potential to have a profound impact upon medical practice. At the center of metabolomics, is the concept that a person's metabolic state provides a close representation of that individual's overall health status...
2016: Metabolomics: Official Journal of the Metabolomic Society
José M Ceriani Cernadas
No abstract text is available yet for this article.
October 1, 2016: Archivos Argentinos de Pediatría
N Krzyżaniak, I Pawłowska, B Bajorek
WHAT IS KNOWN AND OBJECTIVES: When considering acute care settings, such as the neonatal intensive care unit (NICU), the inappropriate use of medicines poses a great risk to vulnerable babies at the start of their lives. However, there is limited published literature that explores the current medication management practices in NICUs and where the main misuse issues lie. Therefore, the purpose of this review was to give an overview of medicine use in NICUs worldwide and identify therapeutic areas requiring more targeted pharmaceutical care...
August 31, 2016: Journal of Clinical Pharmacy and Therapeutics
Marina Sáez Belló, Ana Moya Gil, M Ángeles López Montenegro Soria, Pablo Sánchez Sancho, Pau Frias Ruiz, Mónica Climente Martí
OBJECTIVES: To assess the inclusion of the Therapeutic Drug Monitoring Report (TDMR) in the Electronic Clinical Record (ECR). METHOD: An observational ambispective cohort study with a duration of 149 days: PRE (retrospective, 49 days) with the TDMR printed in paper, and POST (prospective, 100 days) with the TDMR included in the ECR. EXCLUSION CRITERIA: Patients not hospitalized, applications for Therapeutic Drug Monitoring by Critical Care and Neonatal Units, as well as monitoring with an objective other than dose adjustment...
September 2016: Farmacia Hospitalaria
Animesh Biswas, Fazlur Rahman, Charli Eriksson, Abdul Halim, Koustuv Dalal
OBJECTIVES: Social Autopsy (SA) is an innovative strategy where a trained facilitator leads community groups through a structured, standardised analysis of the physical, environmental, cultural and social factors contributing to a serious, non-fatal health event or death. The discussion stimulated by the formal process of SA determines the causes and suggests preventative measures that are appropriate and achievable in the community. Here we explored individual experiences of SA, including acceptance and participant learning, and its effect on rural communities in Bangladesh...
2016: BMJ Open
Sattam Alenezi, Janine Abramson, Coral Smith, Helen Sammons, Sharon Conroy
BACKGROUND: Prescribing errors have the potential to adversely affect the safe pharmacological treatment of patients of all ages. The multi-centre General Medical Council commissioned 'EQUIP' study assessed the prevalence and nature of prescribing errors and found a mean rate of errors in 8.9% of medication orders.1 Paediatric data was not however analysed separately. Errors have been estimated to cause harm in paediatric patients three times more often than in adults.2 Clinical pharmacists play a role in identifying prescribing errors and minimising harm but this role has not been explored in detail in children in the UK...
September 2016: Archives of Disease in Childhood
Gareth Kitson
AIM: Since the introduction of NICE guidance for Early Onset Neonatal Sepsis (EONS)1 in August 2012, the number of locally reported prescribing and administration errors involving gentamicin has increased. This guideline introduced a new, unfamiliar regimen to staff working on the Neonatal Units and Postnatal wards. Analysis of the errors suggested 36 hourly frequency of gentamicin contributed to the errors due to the complexities of prescribing on the paper drug chart. Our aim was to reduce errors involving gentamicin through the introduction of a Microsoft Excel® based electronic prescription chart...
September 2016: Archives of Disease in Childhood
Roland A Snijder, Toine C G Egberts, Peter Lucas, Petra M A Lemmers, Frank van Bel, Annemoon M D E Timmerman
BACKGROUND: Drug administration on the neonatal intensive care unit is often associated with adverse events. This may be due to dosing errors caused by multi-infusion setups. We aim to investigate these dosing errors. MATERIAL AND METHODS: N=3 experiment using a medication schedule, multi-infusion setup (three pumps) and disposables as applied on the NICU. In-line and real-time absorption spectrophotometry was used with dyes as substitutes for pharmaceuticals. Three flow rate changes lasting 1h were initiated...
October 10, 2016: European Journal of Pharmaceutical Sciences
Lin Chen, Li-Hua Huang, Mei-Yuan Xing, Zhi-Xian Feng, Le-Wen Shao, Mei-Yun Zhang, Rong-Ya Shao
AIMS AND OBJECTIVES: The aim of this study was to develop nursing-sensitive quality indicators consistent with current medical practices in Chinese neonatal intensive care units (NICUs). BACKGROUND: The development of nursing-sensitive quality indicators has become a top priority in nursing management. To the best of our knowledge, there has been no objective, scientific and sensitive evaluation of the quality of NICU nursing in China. DESIGN: A modified Delphi technique was used to seek opinions from experts about what should be used and prioritized as indicators of quality care in NICU nursing...
July 12, 2016: Journal of Clinical Nursing
Natalia Krzyzaniak, Beata Bajorek
OBJECTIVE: The objective of this study was to describe the medication errors in hospitalized patients, comparing those in neonates with medication errors across the age spectrum. METHOD: In tier 1, PubMed, Embase and Google Scholar were searched, using selected MeSH terms relating to hospitalized paediatric, adult and elderly populations. Tier 2 involved a search of the same electronic databases for literature relating to hospitalized neonatal patients. RESULTS: A total of 58 articles were reviewed...
June 2016: Therapeutic Advances in Drug Safety
Florentia Kaguelidou, Frédérique Beau-Salinas, Annie Pierre Jonville-Bera, Evelyne Jacqz-Aigrain
AIM: Term and preterm neonates are at high risk for serious adverse drug reactions (ADRs). METHODS: A descriptive study of reports registered in the French pharmacovigilance database from 1986 to 2012 were obtained. All reports concerning neonates (≤1 month of life) with direct drug exposure were retrieved. Characteristics of the reports, including reported ADR(s), drug(s) and the causality assessment using the French causality assessment method, were described...
October 2016: British Journal of Clinical Pharmacology
Laurene Aydon, Yvonne Hauck, Margo Zimmer, Jamee Murdoch
AIMS AND OBJECTIVES: The aim of this study was to identify factors that influence nurse's decisions to question concerning aspects of medication administration within the context of a neonatal clinical care unit. BACKGROUND: Medication error in the neonatal setting can be high with this particularly vulnerable population. As the care giver responsible for medication administration, nurses are deemed accountable for most errors. However, they are recognised as the forefront of prevention...
September 2016: Journal of Clinical Nursing
Amy J Jnah, Desi M Newberry, Andrea N Trembath, Tracey Robertson, April Downing, Miriam Greene, Kerry Sewell
BACKGROUND: The Neonatal Resuscitation Program's (NRP's) Sixth Edition introduced simulation-based training (SBT) into neonatal life support training. SBT offers neonatal emergency response teams a safe, secure environment to rehearse coordinated neonatal resuscitations. Teamwork and communication training can reduce tension and anxiety during neonatal medical emergencies. PURPOSE: To discuss the implications of variability in number and type of simulation scenario, number and type of learners who comprise a course, and their influence upon scope of practice, role confusion, and role ambiguity...
June 2016: Advances in Neonatal Care: Official Journal of the National Association of Neonatal Nurses
Nai Ming Lai, Siew Cheng Foong, Wai Cheng Foong, Kenneth Tan
BACKGROUND: The increased birth rate of twins during recent decades and the improved prognosis of preterm infants have resulted in the need to explore measures that could optimize their growth and neurodevelopmental outcomes. It has been postulated that co-bedding simulates twins' intrauterine experiences in which co-regulatory behaviors between them are observed. These behaviors are proposed to benefit twins by reducing their stress, which may promote growth and development. However, in practice, uncertainty surrounds the benefit-risk profile of co-bedding...
2016: Cochrane Database of Systematic Reviews
G M El-Chaar, T Supaswud-Franks, L Venugopalan, N Kohn, S Castro-Alcaraz
OBJECTIVE: Gentamicin dosing is highly variable and remains complicated in the neonatal population. Traditional dosing in our unit resulted in an excessive number of elevated trough serum gentamicin levels. We hypothesized that one uniform gentamicin dose for neonates of all gestational ages will reduce the incidence of elevated trough levels from 50 to 10%. STUDY DESIGN: Our prospective, randomized, controlled trial enrolled eligible neonates into two groups, according to gestational age (⩽34 6/7 (group I) and >35 0/7 weeks (group II))...
August 2016: Journal of Perinatology: Official Journal of the California Perinatal Association
Sang Taek Lee, Heeyeon Cho
BACKGROUND: Continuous renal replacement therapy (CRRT) has emerged as the modality of choice for the management of high-risk neonates with acute kidney injury (AKI), inborn errors of metabolism and multi-organ dysfunction. The aim of this study was to evaluate fluid overload (FO) and investigate the factors associated with outcomes in neonates undergoing CRRT. METHODS: We retrospectively reviewed the medical records of 34 neonates with AKI who were admitted to the neonatal intensive care unit (NICU) of Samsung Medical Center, Seoul, Republic of Korea between January 2007 and December 2014 where they underwent at least 24 h of CRRT...
November 2016: Pediatric Nephrology: Journal of the International Pediatric Nephrology Association
Ana Paula Cezar Machado, Catharina Somerlate Franco Tomich, Simone Franco Osme, Daniela Marques de Lima Mota Ferreira, Maria Angélica Oliveira Mendonça, Rogério Melo Costa Pinto, Nilson Penha-Silva, Vânia Olivetti Steffen Abdallah
Pediatric patients, especially those admitted to the neonatal intensive care unit (ICU), are highly vulnerable to medication errors. This study aimed to measure the prescription error rate in a university hospital neonatal ICU and to identify susceptible patients, types of errors, and the medicines involved. The variables related to medicines prescribed were compared to the Neofax prescription protocol. The study enrolled 150 newborns and analyzed 489 prescription order forms, with 1,491 medication items, corresponding to 46 drugs...
December 2015: Cadernos de Saúde Pública
A I Safina, M A Daminova, G A Abdullina
BACKGROUND: The incidence of acute kidney injury (AKI) in neonates in the intensive care units and neonatal intensive care (NICU) according Plotz et al. ranges from 8% to 22% [3]. According to Andreoli, neonatal death due to AKI in NICU amounts up to 10-61% [1]. It should be in the reasons of AKI emphasize.The role of certain drugs, which are widely used in modern neonatology: nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics (aminoglycosides, glycopeptides, carbapenems, 3rd generation cephalosporins), furosemide, enalapril, in contributing to AKI should be emphasized [2]...
2015: International Journal of Risk & Safety in Medicine
M T Esqué Ruiz, M G Moretones Suñol, J M Rodríguez Miguélez, E Sánchez Ortiz, M Izco Urroz, M de Lamo Camino, J Figueras Aloy
INTRODUCTION: Neonatal units are one of the hospital areas most exposed to the committing of treatment errors. A medication error (ME) is defined as the avoidable incident secondary to drug misuse that causes or may cause harm to the patient. The aim of this paper is to present the incidence of ME (including feeding) reported in our neonatal unit and its characteristics and possible causal factors. A list of the strategies implemented for prevention is presented. MATERIAL AND METHODS: An analysis was performed on the ME declared in a neonatal unit...
April 2016: Anales de Pediatría: Publicación Oficial de la Asociación Española de Pediatría (A.E.P.)
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