Background Medication errors are the most common medical errors experienced by patients. Neonates are even more vulnerable to medication errors because of drug dosing that is influenced by weight, gestational age, and postnatal age. Data obtained from the safety reporting system related to medication and fluids events in the neonatal intensive care unit (NICU) from January to August 2017 indicated a high rate of near-misses and errors reaching patients. The top five specific event types related to medication and fluids events were, in the following order: delay, incorrect dose, incorrect frequency, medication packaging issues, and dose omitted.

Methods In September 2017, a project team was formed including members from the following disciplines: neonatology, neonatal nursing, pharmacy, medication safety program, and quality department. Data obtained from the safety reporting system were examined and analyzed. After thorough analysis of the data, the project team agreed to tackle the delay in STAT medication administration in the first cycle of the project. The team also completed a process map and cause and effect diagram to understand the root causes of the delay. The average time required for a STAT medication or fluid to be administered to the NICU patient was 3 hours, and the delay in STAT medication was mainly related to septic shock and suspected sepsis management. To reduce the delay in STAT medication administration, the NICU must be provided with a floor stock of pre-mixed antibiotics that is readily available for administration when required. A standardized order set for septic shock doses was programed in the BestCare System to reduce the time and effort required in generating orders. All the stakeholders involved in the process were made aware of the new changes and a departmental policy was created to guide the staff practice.

Results After the implementation of the pre-mixed antibiotic floor stock and pre-set orders, the turnaround time for administration of STAT medication in the NICU reduced from 3 hours to 1 hour, and there was a 60% reduction in the delay in medication administration events.

Conclusion The new changes in the process impacted positively on patient safety and prevention of harm. They reduced time and redundancy in the previous process. The changes also improved staff satisfaction and reduced the tension that used to result from the frequent communication and follow-ups involved until the appropriate medication was made available for administration.