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Nurses warned over antibiotic dosing mistakes


More than 500 babies have been put at risk after they were given wrong doses of an antibiotic by nurses and doctors, figures have shown.

New guidance on administering gentamicin has been published by the NPSA after it received 507 reports of potential harm.

In the 12 months to March 2009, 23 babies suffered moderate harm from the antibiotic and 483 babies had low or no harm.

One “severe” case was reported in which the baby is still alive, but the NPSA said patient confidentiality prevented further comment.

Administering the drug at the wrong time or “near misses” were the most common mistake - with 182 cases - followed by 124 incidents of “proscribing errors”, such as recording the wrong dose. Babies’ blood levels were incorrectly monitored in 86 cases.

Some children could develop hearing and renal damage as a result, warned NPSA, with other gentamicin side effects including rashes, nausea and vomiting.

Under the new guidance, hospitals in England and Wales must have a protocol on exact dosages and blood monitoring rules.

Jenny Mooney, NPSA’s child health lead, said: “Frontline services should adopt this latest Patient Safety Alert to ensure high standards of care are taken in the prescribing, administrating and monitoring of this drug.”


Readers' comments (2)

  • Chasilou

    As a student nurse we are always encouraged to practise drug calculations everyday so we get used to giving the correct dosages. Since I want to become a paediatric nurse I know that this is very important, the wrong dosage could prove fatal for children and babies.

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  • I would like to reassure Chasilou that as an experienced neonatal nurse I know Gentamicin is one of the easiest antibiotics to prepare for injection. It does not require any mixing or dilution and comes as 10mgs / ml which makes it very easy to calculate. The errors mentioned are not about nurses preparing the drug, but about when they give it. All units have different protocols on how much and at what intervals it is given, according to weight and gestation. Using an extra Gentamicin dosing sheet helps prevent errors of this kind. Problems also arise over taking blood for levels and then obtaining the results prior to the next dose. With fewer medical staff around now it is often left to busy overstretched nursing staff, with resulting omissions. It is helpful if the person giving the present dose, records on the pharmacy chart instructions for the next dose, whether it be taking of blood or checking of results. In a busy unit it can prevent a mistake. However a clear set protocol is mandatory.

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