[Skip to Navigation]
April 1979

Medication Errors During Intensive Care

Author Affiliations

Department of Pediatrics; Department of Pharmacy Practice University of Washington and the Children's Hospital and Medical Center Seattle, WA 98105

Am J Dis Child. 1979;133(4):366-367. doi:10.1001/archpedi.1979.02130040020002

Anyone who has worked in an intensive care unit is aware of the potential for iatrogenic disease due to medication error. No one, however, knows how often medication errors occur. What Perlstein and his associates have attempted, as reported on page 376 in this issue of the Journal, is to quantitate the magnitude of that risk in the neonatal intensive care unit (NICU). Their study suggests that 8% of all doses calculated and administered by experienced registered nurses are ten times greater or less than ordered.

This conclusion was based on the results of a written test given to 95 registered nurses. The test consisted of ten typical NICU drug orders together with the concentrations of available stock solutions and the weight and age of the infant for whom the drug was intended. The test was presented as a mandatory exercise to evaluate nursing skills. It was proctored by supervisory