Clinical pharmacist in competition with medication errors in the neonatal intensive care unit

A medication error is any preventable event that may cause or lead to inappropriate use of drugs or patient harm if it is not under the control of the health care professional. Despite the fact that healthcare professionals take the responsibility very seriously, it has been estimated that 250 000 Americans die annually due to medication errors [1]. Although, estimates show that one in ten patients worldwide is affected by medication errors while receiving hospital care, the harm can be caused by a range of incidents or adverse events [2]. The exact incidence of medication errors in the neonatal intensive care unit (NICU) is unknown. In neonates especially premature infants, the immaturity of developing body systems affects the absorption, distribution, metabolism and excretion of drugs and therefore an exponential risk for medication errors is present [3]. The risk of medication errors in children are much greater than adults [4]. Neonates are at a high risk for medication errors because of incorrect calculation of doses individually that should be based on age, weight and surface area as well as inadequate information. In addition, lack of suitable dosage forms and concentrations and need for complex calculations or dilutions by medical staff including nurses, physicians and pharmacists [5]. Medication errors can occur at several steps in patient care, from ordering the medication to the time when the patient is administered the drug [6]. To the best of our knowledge, there is no uniform definition and protocol of a medication errors in Libyan hospitals. Therefore, from my experience in NICU at Tripoli University Hospital (TUH), a view point and the role of a clinical pharmacist towards medication errors seems to be an issue of concern. To clarify this point, some examples of medication errors in NICU at TUH are shown in Table 1 and the expected risk that may occur with corrections of such errors are also give