Advances in Neonatal Care: Medication Safety in the Neonatal Intensive Care Unit: Position Statement #3073


A medication error is any “preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer.”1 Unfortunately, medication errors in the neonatal intensive care unit (NICU) are common, and when they occur, they are more likely to result in harm than medication errors that occur with other patients in the hospital.2,3 Research reports demonstrate that many medication errors in the NICU are preventable.4 The medication use process is inherently risky in the NICU due to the vulnerable patient population, complexity of both medications and medication administration, and the unique NICU environment. The National Association of Neonatal Nurses (NANN) recognizes these unique challenges and offers a revised and updated “Medication Safety in the Neonatal Intensive Care Unit” position statement that outlines recommendations and suggests safeguards and practices to ensure medication safety in the NICU.

The revised position statement includes recommendations specific to the NICU as an adjunct to national and applicable state standards. A focus on the prevention of medication errors suggests system-wide practices, including prescriber computer order entry, standard formularies, use of barcode administration systems, smart pump technology, involvement of clinical pharmacists on rounds, and the use of hardwired safety checks. The position statement emphasizes that promoting a safety-conscious culture without overreliance on technology is the most comprehensive strategy to prevent medication errors.

NANN supports a team approach to medication safety, recommending that all safety efforts be regularly communicated to NICU staff with a focus on problem-prone processes and prevention strategies. The position statement recommends a multidisciplinary and collegial approach that strives to develop standardized medication safety practices in the prescribing, dispensing, and administration of medications in the NICU. In support of these efforts, a robust plan for monitoring and reducing medication errors is critical.

Ref: doi: 10.1097/ANC.0000000000000956