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The problem with gentamicin: reducing administration and prescribing errors in neonates treated for early onset infection with gentamicin
  1. Ashifa Trivedi1,
  2. Elizabeth Lek2,
  3. Sadhna Sharma1,
  4. Shavindra Chellen2
  1. 1 Pharmacy Department, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
  2. 2 Neonatal Department, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
  1. Correspondence to Mrs Ashifa Trivedi, Divisional Pharmacist Women and Children, Hillingdon Hospitals NHS Foundation Trust, Uxbridge UB8 3NN, UK; ashifa.trivedi{at}


We describe a quality improvement (QI) project to reduce the number of administration and prescribing errors with gentamicin on a local neonatal unit in a district general hospital, from January 2017 to August 2019. Baseline data collected showed seven errors in the first 16 months of the project (from 1999 doses). The aim of this QI project was to have no low-level, moderate-level or severe level harm errors in the intervention period. A number of interventions were carried out including a change to local guidelines and teaching sessions for staff. All Datix reports for gentamicin were reviewed as well as data collected from the pharmacy team for a further 16 months. One low harm error was reported in this period (from 1938 doses). Education of the medical and nursing staff has been a key intervention in reducing our gentamicin errors as well as changing the way we prescribe gentamicin.

  • audit
  • data collection
  • multidisciplinary team-care
  • neonatology

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. We now have data available from September 2019 - February 2020 which has not been included in this manuscript as this is beyond the intervention period. We have however not had any further errors in this extended time.

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What is known about this topic?

  • Gentamicin is a complex high-risk medication with a narrow therapeutic index. We have not been able to identify any studies looking at error rates with gentamicin but local studies show that the majority of errors are reported as prescribing errors compared with administration errors.1 5 6 Previous studies have shown that multiple interventions can help to reduce errors with administration and prescribing.1 5 6

What this study adds

  • To our knowledge previous studies have focused only on interventions to help reduce prescribing errors with medical and non-medical prescribers. No previous studies have included educational sessions for nursing or pharmacy staff. We highlight the importance of including all members of staff in order for change to be successful. We are also not aware of any studies that have covered this length of time.


We describe a quality improvement (QI) project, aiming to reduce administration and prescribing errors with gentamicin, in a local neonatal unit using a number of interventions.

The problem

Seven errors were reported through our trust error reporting system, Datix, from January 2017 to April 2018, with either the prescribing or administration of gentamicin. From these errors, four were missed doses, two were doses given 12 hours too early and one was a dose given despite a high trough level. Data for the baseline period were collected retrospectively using both the Datix reporting system and pharmacy error data.

We have implemented two key interventions to reduce the number of errors. The first was to bring our gentamicin prescribing in line with National Institute for Health and Care Excellence (NICE) CG149 guidance1 and the second was an education programme for all staff involved in gentamicin prescribing and administration.


Gentamicin is an aminoglycoside, active against many strains of Gram-positive and Gram-negative pathogens. To avoid toxicity measuring trough concentrations is necessary as there are potential side effects of nephrotoxicity and ototoxicity.2

NICE advises using intravenous benzylpenicillin and gentamicin for the prevention and treatment of early onset neonatal infection. Antibiotics for early onset neonatal infection are commenced based on risk factors or clinical symptoms.2

Prescribing of gentamicin is complex, as it involves using weight and age to calculate dose and frequency, respectively, alongside obtaining levels in a timely manner.

Our local guideline for gentamicin prescribing was as follows3 (table 1):

Table 1

Old guideline for prescribing gentamicin


Our aim was to have no low-level, moderate-level or severe-level harm errors in the intervention period.

Making a case for change

The project was led by a neonatal consultant and the divisional lead pharmacist. It was very important for us to include all members of the team and to understand their problems and concerns. The project team consisted of a junior pharmacist, a paediatric trainee, the neonatal nurse manager and the neonatal practice educator. Following feedback from the nursing staff we understood that the current prescribing of gentamicin was very confusing for them and they were unsure of when to take levels and what to do if the level was high. Similarly junior pharmacists covering the ward did not feel confident to provide advice on problems with levels. By involving staff in small focus groups, we were able to involve them in the discussion process and discuss potential solutions together. When we implemented our interventions, as staff had been part of the process, they were already aware of the new proposed changes which led to a seamless transition.


Changes using Plan-Do-Study-Act (PDSA) cycles:

PDSA cycle 1: Guideline change

In line with NICE2 and the British National Formulary for Children 4 our local guideline was changed (table 2). This allows for the same doses to be given to both preterm and term babies.

Table 2

New guideline for prescribing gentamicin

PDSA cycle 2: Laminated guides on gentamicin dosages and table for administration

We brainstormed ideas with our focus groups to help doctors, nurses and junior pharmacists understand when doses of gentamicin were due and when to take levels. This led to the creation of a gentamicin prescribing guide and information about when to take levels (figures 1 and 2). These were displayed at strategic places on the NNU and transitional care unit for easy reference. This helped to avoid confusion among medical staff and nurses and in turn reduced errors.

Figure 1

When to take gentamicin: trough levels—guide for medical staff.

Figure 2

When to take gentamicin: trough levels—guide for nursing staff.

PDSA cycle 3: Teaching session for junior pharmacists

The junior pharmacist on rotation at the time was involved in this QI project. They were involved with the teaching sessions and the creation of the prescribing guide. Furthermore, the pharmacy department were notified of the change in dosing, to ensure all members of the pharmacy team felt confident in screening gentamicin and giving advice where appropriate.

PDSA cycle 4: Regular teaching sessions for nurses

Every 3 months neonatal nurses attended a study day, which included a pharmacist-led teaching session. At the teaching session the change to the guideline was discussed including the role of nursing staff when administering gentamicin. Many were unclear on when a level should be taken, what the level should be and what to do if a level was high.

All gentamicin errors were reported on the Datix system. Nurses and doctors involved in any errors were debriefed by their respective nurse manager or consultant. We asked permission to anonymously share any gentamicin errors with the rest of the neonatal department to prevent the same errors from being repeated.

Previous errors were used as scenarios to discuss what should or could have been done differently. Nursing staff reported they were very pleased with the changes because this meant prescribing was simplified. They were pleased to be part of the change process and have their concerns addressed. In particular they found using real life examples extremely useful.

PDSA cycle 5: Regular teaching sessions for doctors

Teaching sessions were also held for junior doctors when they started in the department during induction. The early onset guidelines were discussed by the consultant and the divisional pharmacist presented a session on drug prescribing which included gentamicin.

PDSA cycle 6: Standard drug charts for neonates

At our trust we use paper drug charts and the same drug chart is used across the neonatal and paediatric wards. We discussed the idea of designing a specific drug chart for use on the neonatal unit but felt that PDSA cycles 1–5 had been sufficiently successful. We are aware that other trusts have a specific drug chart for prescribing antibiotics for neonates. This potential intervention may be revisited if we notice an increase in errors despite our current interventions.


We audited the number of gentamicin doses given in both the baseline and intervention periods.

There were more individual babies requiring antibiotics in our intervention period despite a small reduction in the number of doses from 1999 (preintervention) to 1938 (intervention).

In our baseline period (January 2017 to April 2018) there were seven errors from 1999 gentamicin doses given (0.35%) (figure 3). Four were missed doses, two had incorrect frequencies prescribed and one had a high trough level not acted on. The shortest time between errors was 6 days and the longest was 259 days.

Figure 3

Graph showing the number of gentamicin doses and errors during the preintervention and intervention periods. PDSA, Plan-Do-Study-Act.

We report one error from 1938 gentamicin doses (0.05%) in the intervention period which was a missed dose (low-level harm). No harm came to the baby and they continued antibiotics for 5 days. There was a significant fall in our gentamicin error rate from 0.35% to 0.05% (p=0.038) during our intervention period. Of note the one error that occurred took place in May 2019. The error prior to this occurred in April 2018.

Although we have not achieved our aim of no low-level, moderate-level or severe-level harm errors in the intervention period, we have been able to maintain no errors for the last 14 months (from October 2018 to November 2019).

Learning and next steps

The intervention with the most success was ensuring we engaged the nursing staff in order to understand the proposed changes to the gentamicin guideline. Education of the medical, nursing and pharmacy staff has been a key intervention in reducing our gentamicin errors. We recognise that education alone does not always result in sustained improvement and therefore having prescribing guides to make it easier for staff to follow the correct process thereby reducing variation and the number of errors has been invaluable.

Discussing errors in a timely manner has helped prevent the risk of the errors reoccurring. Identification of drug errors relies on reporting through the Datix system. Errors could potentially be under-reported, however a pharmacist is present on the ward Monday–Friday and so we feel that they would most likely identify any errors. All staff members must be encouraged to report errors when they occur to maintain an environment of learning and safety.

We have maintained the regular teaching sessions with both the medical and nursing staff. We feel that as a result of this we have been able to maintain a period of no errors for the last 14 months and we hope to be able to continue this success.

Changing our gentamicin prescribing in line with NICE CG1492 may have also assisted our aim in reducing errors twofold. First staff that may have joined around the time changes had been made may have already been familiar with the new dosing and interval regime from their previous trust. Second, moving to 36 hourly gentamicin dosing for all gestations reduced the chance of confusion in comparison to the more complex previous regime.

Although our gentamicin error rate has been low since our interventions, many units have a separate gentamicin prescription chart, and as a unit we are considering if this would be possible for us to do as well (PDSA cycle 6).

This QI project highlights the importance of education among all levels of staff in reducing gentamicin errors in our unit. With continued teaching sessions and gentamicin training for all staff members during induction, it is hoped that this trend of no gentamicin errors can be sustained leading to better patient safety.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. We now have data available from September 2019 - February 2020 which has not been included in this manuscript as this is beyond the intervention period. We have however not had any further errors in this extended time.



  • Contributors AT and EL conceived the idea for this quality improvement project. AT, EL, SS and SC have coauthored the manuscript. SMY and CM helped collect data for this project and were responsible for leading the education and training of nursing staff.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.