NICU medication Errors

Medication errors are scary in any setting but in the NICU they have the potential to be devastating. NICU patients are among the most vulnerable in the hospital with many micro preemies weighing in at less than 2 pounds. NICU nurses, physicians and midlevel providers must fully appreciate the danger of giving such a tiny patient an overdose of a potent medication and exercise every caution to prevent it from happening.

Hospitals have built in safety guards for the most toxic medications, but for these safety guards to work, the staff must diligently follow the protocols set up to protect these tiny vulnerable patients. All too often in the hustle and bustle of a busy unit, safety protocols will be skirted to save time. The results of this kind of carelessness can be fatal.

One of the most important safety guards put in place by healthcare facilities is the classification of a drug as high risk or high alert. If a drug is designated high risk then the requirement is that 2 RNs must verify the dose before that drug is administered to the patient. The verifying RN must sign the Medication Administration Record (MAR) taking responsibility for the verification of that dose. If done properly and as intended dual verification of a high risk medication should prevent most dosage calculation errors.

The problem comes when this safety guard protocol is NOT followed properly, essentially skirting past the very safety net put in place to protect the patient from harm. In the NICU most any medication is going to be a weight based dose, something along the lines of mcg/kg/min. To administer the correct dose the NICU RN must make this calculation correctly. Just one decimal place off can be a fatal miscalculation.

Digoxin and Insulin are examples of 2 high risk drugs administered in the NICU every single day. Both are extremely toxic if given incorrectly and both are classified as high risk or high alert medications requiring dual verification before administration. The correct dual verification procedure would look like this:

• The RN administering the medication looks at the order, looks at her/his patient's weight and looks at the concentration of the drug vial being used, then calculates the correct dose for the drug. The RN then draws up that dose into the appropriate syringe.

• Before administering the dose to the NICU patient, the RN will ask a second RN to verify or double check her/his dosage calculation.

• The second RN then, without looking at the syringe with the dose drawn up, does a "blind" verification by looking at the order, looking at the patient's weight, looking at the concentration of the drug in the vial and saying what dose she would draw up into the syringe. The first RN will then present her/his filled syringe to the verifying RN who will verify that the dose drawn up matches what she/he calculated should have been drawn up.

• The verifying RN signs the MAR verifying that she/he has double checked the dose before it was administered.

That is how it should work. Unfortunately what happens all too frequently is this:

• The RN administering the medication looks at the order, looks at the patient's weight and looks at the concentration of the drug vial being used, then calculates the correct dose for the drug. The RN then draws up that dose into the appropriate syringe.

• Before administering the dose to the NICU patient, the RN will find a second RN and say something like "Hey, I am getting ready to give 1 mL which is 250 mcg of Digoxin to Baby Smith, would you double check my dose."

• First RN then holds up a syringe with a clear liquid drawn up to the 1 mL line and second RN says "Yep, that is 1 mL of Digoxin" and signs off on the MAR that she/he has double checked the dose before it was administered.

That sounds so careless, reckless and negligent yet is, unfortunately, something that happens very single day on busy units everywhere. As you can see the only thing the second RN essentially verified in the above scenario is that the first RN is giving 1 mL of something that looks like a clear liquid to Baby Smith. It could be anything and maybe the first RN miscalculated and the dose should have been .25 mL or .5 mL. The safety guard put in place by the facility is basically useless when busy nurses skirt around the edges of the protocol. An error like described is very serious on any patient care unit but in the NICU a medication error like this can be fatal very quickly.

I recently consulted on 2 malpractice cases involving medication errors in the NICU. Both involved high risk medications such as Digoxin. In one case, the administering RN just entirely skipped the dual verification process and give 10x the ordered dose after a miscalculation. That kind of blatant disregard for safety protocols made it very easy for the plaintiff attorney to prove a standard of care violation. In the second case the RN had a second nurse "verify" the dose but even though the original dose had been miscalculated the second RN failed to catch it. When asked, she had to admit that she had not actually performed the calculation but had just verified the number of milliliters of liquid in the syringe. Two examples of carelessness that can lead to devastating consequences for a

helpless and vulnerable baby.

RNs, physicians, and midlevel providers need to make sure that every single time they give a medication they are following every safety protocol set in place by the facility. No matter how busy they are, no matter how many other patients they have, it simply has to be done correctly. If the RN administering the medication asks another RN to dual verify and they baulk at doing it correctly and want to "just see what you have drawn up" , insist they do it correctly before them signing off on your patient's MAR or find a different nurse to verify. It is that important.

Veritas Med-Law can provide customized training for your staff on important patient safety topics like medication administration and defensive documentation. We also provide risk evaluation consulting services and can help you identify weaknesses and problem areas and make recommendation to correct them.