A Summary of NICU Fat Emulsion Medication Errors and Nursing Services

Abstract

Intralipid infusions remain a critical part of ensuring adequate nutritional supplement and growth in premature and term infants. Managing intralipid therapy requires great care to prevent metabolic and physiological side effects. The authors sought to systematically study medication errors associated with intralipid administration in the neonatal intensive care unit (NICU). A descriptive quantitative and qualitative analysis incorporating secondary data was used. Medication error data were drawn from 54 institutions that voluntarily participated with MEDMARX, a national, Internet-accessible medication error reporting program owned and operated by the United States Pharmacopeia. These errors were associated with NICUs, and each medication error record identified nursing staff as making the initial error. A total of 257 errors were reviewed, with 3.9% resulting in harm. The mean age of the neonate was 7 days, and more errors occurred on Mondays than any other day of the week. Errors disproportionately occurred between 6 pm and midnight, with a significant difference between errors near 7 am and 7 pm (P = .002). Wrong dose errors occurred in 69% of the sample. Nearly one quarter of the errors resulted from misprogramming infusion devices (either pumps or syringes). Qualitative findings revealed that many of the errors were the result of the nurse's misinterpretation of the modes (ie, time, volume, or rate) on the infusion device or by not recognizing the decimal point on the device's display panel. Several errors involved switching the rate of infusion with total parenteral nutrition and that of intralipids. Voluntary medication error reporting offers valuable insights into intralipid errors occurring in NICUs. Secondary analysis is an ethical, economic means of studying the occurrence of such errors. MEDMARX data suggest that some of the serious errors are the result of complex care and equipment needed for these vulnerable infants.

Intravenous Milk Infusion; Rare Medication Error

“…In 2007 MEDMARX (the largest medication error internet reporting program in United State) published a study of NICU fat emulsion medication errors and nursing services including prescription, preparation and administration. They reviewed a total of 257 errors with 3.9% error resulting in harm, the mean age of affected neonates were seven days, and more errors occurred on Monday than any other days of the week, wrong dose errors occurred in 69% of the sample [3].…”

“…The reported complications of milk injection in neonates were: hyperosmolarity, micro embolism, hypersensitivity, apnea, respiratory distress, septicemia, neutrophilia, seizures, multiple organ failure and death [1][2][3][4][5][6][7].…”

“…These errors may cause harmful effects including death [2]. Although these errors can be caused by system defects or human mistakes, the person is responsible for initiating the error [3]. Reporting medication errors during practice help caregivers to provide the proper management and to expect possible complications when similar errors happen.…”

Administración de la nutrición parenteral pediátrica

“…En estos casos, el contenedor de la emulsión lipídica se empleará durante un máximo de 12 horas, desechando al final de este periodo la porción sobrante (4,9,10). Antes de comenzar la administración de los lípidos, hay que comprobar que la bomba está correctamente programada y la velocidad coincide con la prescrita (11).…”

Anaphylaxis Development after Intravenous Injection of Cow’s Milk

“…Most of the cases reported in the literature are erroneous accidental intravenous administration of enteral feeding formula and maternal breast milk (Table 1) (1,2). Although rare, intravenous injection of formulas in childhood can cause fatal complications (1)(2)(3).…”