Abstract

The unique and complex care environment in the NICU, as well as the vulnerability of neonatal patients, results in a high-risk environment for medication errors.1 NICU patients are disproportionately affected by medication errors,2 with one study showing almost one-fifth of all medication errors in pediatric teaching hospitals occurring in the NICU.3 Another study of 2 children's hospitals showed that nearly half of all medication errors occurred in the NICU, with 37% of those errors occurring in patients younger than 1 month.4 Medication error rates are inversely related to the patients gestational age and birth weight, with younger and smaller neonates being affected the most.5,6 Reasons for this include their premature organ systems, leading to altered absorption, distribution, metabolism, and excretion of medications, as well as their acuity, prolonged length of stay, inability to communicate, and rapidly changing body size.