Improving Safety Throughout the Medication Use Process in a Neonatal Intensive Care Unit

Abstract

Safety is the top priority for our institution. Safety has been reinforced since it became a priority of federal and state governments, the Institute for Safe Medication Practices (ISMP), and accrediting bodies (eg, the Joint Commission on Accreditation of Healthcare Organizations [JCAHO], the National Committee for Quality Assurance). Neonatal practice has required additional attention because of the nature of the specialty and the high-risk drugs and patients in this practice area. Our institution created several multidisciplinary teams to address deficiencies in our medication use process. Each team had a member from the nursing staff, neonatology staff, nurse practitioner group, and a clinical pharmacy specialist; the neonatal intensive care nurse manager and pharmacy manager were ad hoc members. The systems involved defining and standardizing prescribing practices and processing and administration of medications. This paper is a description of changes made in a hospital medication use system without direct evaluation of the implementation of the changes. All the changes were successfully implemented within a 10-month period (September 2004 through June 2005) that encompassed 7 steps, including the elimination of the rule-of-6 method of drug preparation and administration, and utilization of an infusion device with decision-support software (smart pump).