Medication error in an extremely low birth weight newborn: paracetamol overdose

Abstract

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.

Acetaminophen and Acetylsalicylic Acid Exposure in a Preterm Infant after Maternal Overdose

“…There have been few case reports illustrating the use of NAC in neonates after accidental overdose. [10][11][12][13] There are even fewer that describe situations warranting NAC due to in utero exposure to APAP. 14,15 Steroid use has been reported as a cause of drug-induced liver injury in adult patients, but no reports of antenatal steroids contributing to hepatotoxicity in neonates have been reported.…”

Neuroprotection in Perinatal Hypoxic-Ischemic Encephalopathy — Pharmacologic Combination Therapy

“…The changing between administration routes, introducing deviations from "standard" treatment, may decrease these side effects (Bebarta et al, 2010). In a medication error in prescribing paracetamol for closing a patent ductus arteriosus in a preterm infant, NAC was indicated without showing adverse drug reactions (Brener et al, 2013).…”