Document Detail

Medication error in an extremely low birth weight infant: paracetamol overdose.
MedLine Citation:
PMID:  23381705     Owner:  NLM     Status:  In-Data-Review    
Errors are part of human nature and are usually present in our actions. Medical errors occur quite often and can be serious. Medication errors are among the most frequent, especially in newborn infants because of the multiple steps that occur during the process of prescribing and administering drugs and because most drugs are not licensed for being used in newborn infants (off-label). The aim of this report is to describe a medication error in prescribing paracetamol for closing a patent ductus arteriosus in a preterm infant and to analyze its causes. A preterm female infant born at 27 weeks of gestational age with a birth weight of 750 g received paracetamol at 9 days old at a dose 20 times greater than required. The initial plasma level was 480 µg/mL. N-acetylcysteine was administered and her clinical outcome was satisfactory. Parents were notified of the event, which was recorded in the medical record and in the electronic error reporting system of the Hospital Italiano de Buenos Aires. We consider this report as an example that we are exposed to making mistakes and should maximize precautions to improve patient safety in neonatal units.
Pablo Brener; Mónica Ballardo; Gonzalo Mariani; José M Ceriani Cernadas
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Archivos argentinos de pediatría     Volume:  111     ISSN:  1668-3501     ISO Abbreviation:  Arch Argent Pediatr     Publication Date:  2013 Feb 
Date Detail:
Created Date:  2013-02-05     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0372460     Medline TA:  Arch Argent Pediatr     Country:  Argentina    
Other Details:
Languages:  eng; spa     Pagination:  53-5     Citation Subset:  IM    
Division of Neonatology, Department of Pediatrics, University Institute, Hospital Italiano de Buenos Aires.
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