Applying root cause analysis to promote the medication safety of continuous drug infusions for infants
Journal
Journal of Nursing
Journal Volume
61
Pages
S14
Date Issued
2014-04-01
Author(s)
Abstract
Background & Problems: An adverse medication event involving a continuous drug infusion dosage error was reported in the infant intensive care unit of our hospital in 2010. The causes of this adverse medication event were elicited in the healthcare network using root cause analysis. These causes included incomplete procedures and incorrect prescription, an incomplete procedure of medication in continuous drug infusion, complex procedures in confrming prescription, the transcription of doctor's orders and prescription (i.e., kardex), and defcient knowledge of medication procedures exhibited by clinical nurses.
Subjects
Adverse medication event | Continuous intravenous drug infusion | Infants | Medication safety | Root cause analysis
Type
journal article