Is Hyperbilirubinaemia a Clinical Useful Indicator of Reduced Drug Clearance Capacity in Neonates?

Abstract

Case reports and observational studies continue to report adverse events from medical errors. However, despite considerable attention to patient safety in the popular media, this topic is not a regular component of medical education, and much research needs to be carried out to understand the causes, consequences, and prevention of healthcare-related adverse events during neonatal intensive care. To address the knowledge gaps and to formulate a research and educational agenda in neonatology, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) invited a panel of experts to a workshop in August 2010. Patient safety issues discussed were: the reasons for errors, including systems design, working conditions, and worker fatigue; a need to develop a “culture” of patient safety; the role of electronic medical records, information technology, and simulators in reducing errors; error disclosure practices; medico-legal concerns; and educational needs. Specific neonatology-related topics discussed were: errors during resuscitation, mechanical ventilation, and performance of invasive procedures; medication errors including those associated with milk feedings; diagnostic errors; and misidentification of patients. This article provides an executive summary of the workshop.

A study of medication errors during the prescription stage in the pediatric critical care services of a secondary-tertiary level public hospital

“…Medication errors occur frequently in pediatric critical care settings affecting patient safety and quality of healthcare [ 15 , 26 , 27 ]. According to our knowledge, this is the first study reporting pediatric MEs in emergency and intensive care services in Mexico.…”

“…In addition, it has been reported that neonates are particularly vulnerable to the consequences of MEs as they are smaller in size and fragile, generally with immature organ systems. Therefore, the timely detection and prevention of MEs in neonates is particularly important given that neonates and premature infants are at high risk for error [ 9 , 41 , 42 ], with even minor errors possibly leading to short and long-term norm [ 26 ].…”

Phenotyping for patient safety: algorithm development for electronic health record based automated adverse event and medical error detection in neonatal intensive care

“…This trigger has also been implemented by manual ME trigger tools. 7 Less severe infiltrates not requiring hyaluronidase may be described in the clinical notes. Therefore, we also annotated clinical notes for IV infiltrates.…”

“…The trigger or unexpected sign and symptom step in the algorithm mirrors the approach that has been implemented by widely-used manual ME trigger tools. 7 In addition to narcotic oversedations, non-standard narcotic orders, narcotic medication delivery errors, and frequency errors were also detected.…”

“…Many gaps remain in our understanding of AEs/MEs that occur in the NICU. 7 Trigger tools and voluntary incident-reporting systems are the most prevalent error-detection methods in healthcare institutions. 8–10 Other methodologies include screening administrative data (eg, ICD-9-CM) codes.…”