Medication errors in oral dosage form preparation for neonates: The importance of preparation technique

Objective: Considering the inability of neonates to swallow oral drugs in the form of solid tablets, the lack of appropriate dosage forms for infants, and the necessity to prepare some pills for neonates, the current study investigated dosage accuracy in drugs for neonates prepared from tablets by analyzing the concentrations of final products. Methods: Captopril and spironolactone, oral dosage forms that are not suitable for infants, were chosen as the drug model for this study. Demographic characteristics of nurses providing medications and tablet preparation methods were documented in a random observational method. To determine concentrations of final solutions, 120 drug samples (60 captopril and 60 spironolactone samples) prepared by Neonatal Intensive Care Unit nurses of the Children Cure and Health Hospital of Tabriz University of Medical Sciences were analyzed using high performance liquid chromatography (HPLC) and spectrophotometry. Findings: There was a significant error rate in the concentration of captopril in prepared solutions compared with the ordered dosage. No differences were observed in the demographic characteristics of the nurses and the method of preparation between the two drugs. The only difference related to the preparation technique was that in most cases (70.8%), one whole spironolactone tablet was used, whereas in around 50% of samples in captopril group, half or a quarter of one captopril tablet was utilized for the intended dosage (P = 0.009). Conclusion: This research suggests that the use of a whole tablet instead of a divided tablet in the manual preparation of medication dosage forms for neonates is the most appropriate approach.