The NPSA has issued a Patient Safety Alert concerning the safer use of intravenous (IV) gentamicin in neonates, following safety incidents involving administration at the incorrect time, prescribing errors and issues relating to blood level monitoring.

A total of 507 patient safety incidents relating to the use of IV gentamicin were reported to the Reporting and Learning System (RLS) between April 2008 and April 2009 – this constituted 15% of all reported neonatal medication incidents.  The most common errors included administration at the incorrect time (36%), prescribing errors (24%), and issues relating to blood level monitoring (17%).  A total of 4% of these incidents (n=23) were reported as causing moderate harm (long-term side-effects from gentamicin toxicity may not be captured in incident reports).  

All NHS organisations responsible for the provision of neonatal services should ensure that by 9 February 2011:

 
• A local neonatal gentamicin protocol is available that clarifies the initial dose and frequency of administration, blood level monitoring requirements, and arrangements for subsequent dosing adjustments based on these blood levels;

• Local policies and procedures are developed or revised to state that IV gentamicin should be administered to neonates using a care bundle incorporating the following four elements:

- When prescribing gentamicin the 24 hour clock format should be used and unused time slots in the prescription administration record blocked out to prevent wrong time dosing.

- Interruptions during the preparation and administration of gentamicin should be minimised by the wearing of a disposable coloured apron by staff to indicate that they should not be disturbed.

- A double checking prompt should be used during the preparation and administration of gentamicin.

- The prescribed dose of gentamicin should be given within one hour of the prescribed time.

• Neonatal units implement this care bundle using small cycles of change with a sample group of patients.

• Compliance with the care bundle is measured daily for each patient in the sample group until full compliance for all patients receiving gentamicin is achieved.

• All staff involved in the prescribing and administration of IV gentamicin are provided with training relating to its use. This should include education regarding the interpretation and management of gentamicin blood levels including actions to be taken in relation to dose or frequency following a blood level result.

 
The NPSA has produced a range of information and materials to support implementation – this includes a guide to implementation, a double checking prompt, audit chart, compliance chart, training presentation, and an FAQ.  Please see the links below for further details.