MEDICATION ADMINISTRATION ERRORS IN NEONATAL INTENSIVE CARE UNITS: AN INTEGRATIVE LITERATURE REVIEW

Abstract

INTRODUCTION: The Neonatal Intensive Care Unit (NICU) provides comprehensive care to critically ill newborns, requiring safe practices, especially in the preparation and administration of medications. Errors in this step can cause significant harm to the patient, increasing morbidity and mortality. Due to the physiological vulnerability of neonates and the particularities of drug therapy — such as weight-adjusted dosages and communication difficulties — there is a greater propensity for failures, reinforcing the need for rigorous protocols. Medication errors are considered avoidable adverse events, and can occur in several phases, such as prescription, preparation, dispensing, and administration. OBJECTIVE: To analyze the available evidence on the most common errors in medication administration in NICUs. METHODOLOGY : This is an integrative review based on the methodology of Whittemore and Knafl (2005). The search was carried out in the Web of Science, PubMed, Scopus, Embase, and CINAHL databases, in March 2025, using specific strategies for each database. After screening and inclusion criteria, 12 studies were selected for analysis. RESULTS:  The analysis of the studies revealed methodological diversity, with a predominance of observational and documentary studies in different countries. The most prevalent errors involved illegibility of prescriptions, erroneous dosage calculations, preparation failures such as non-homogenization of the drug, in addition to delays in administration, inadequacy of the infusion route and speed, and problems with the management of infusion pumps. Serious errors, such as administering tenfold doses and failures in critical medications, were also observed. Organizational factors, such as insufficient nursing staff and similarity between medication packaging, contributed to the increase in errors. The prevalence of underreporting makes it difficult to assess the scenario and implement improvements in the health service. FINAL CONSIDERATIONS: It is concluded that the NICU environment requires continuous interventions to prevent errors, professional training and strengthen the safety culture, aiming to protect the health of neonates and promote safer care practices.