Error de medicación en un prematuro de extremo bajo peso: sobredosis de paracetamol

Abstract

Errors are part of human nature and are usually present in our actions. Medical errors occur with high frequency and can be serious. Medication errors are among the most frequent especially in neonates, because of the multiple steps that occur during the process of prescribing and administering drugs and because the vast majority of the drug is not licensed for using in neonates (off-label). The aim of this report is to describe a medication error in prescribing acetaminophen (also called paracetamol) for closing a patent ductus arteriosus in a premature neonate, and to perform an analysis of its causes. A premature female infant born at 27 weeks' gestation with a birth weight of 750 g, received acetaminophen at 9 days old at a dose 20 times higher than that required. The initial plasma level of the drug was 480 μg/ml. N-acetylcysteine was administered and her clinical outcome was satisfactory. Parents were informed of the event being stated in the medical record and the system of electronic reporting errors of the Hospital Italiano de Buenos Aires. We consider this report as an example that we are exposed to commit errors and should extreme caution to improve patient safety in neonatal units.