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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. 1Pharmacy Department, Hillingdon Hospitals NHS Foundation Trust, Uxbridge, UK
  2. 2Neonatal 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
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  • 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.

  • Patient consent for publication Not required.

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

  • 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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