Administration of intravenous morphine to neonates

It is routine practice within neonatal units to administer intravenous morphine as a painkiller to babies requiring mechanical ventilation. Intravenous medicines are often only available in adult strengths and must be diluted accurately before being given to newborn babies. The drug preparation is a complex procedure. Mistakes made when calculating, measuring or mixing these injections can result in administering the wrong amount of medicine. Small, vulnerable babies, such as those born prematurely, can be particularly sensitive to medicines and errors have caused severe harm in some cases.

We know from previous studies that an error occurs when diluting this drug in around one in five cases, in spite of protocols where calculations and measurements are double-checked to minimise risk.

Our team is in the early stages of developing a bedside device with the ability to identify intravenous medication errors prior to administration to neonates. We are currently seeking funding in order to investigate whether introducing a point-of-care monitoring device into neonatal units can reduce the incidence of intravenous morphine administration errors.

We worked with the team at the newborn baby unit at Brighton and Sussex University Hospital. First, we used the device to measure the amount of morphine in syringes that have been prepared on the unit and checked that they agreed with measurements determined in a laboratory. Next, we investigated whether using the device can reduce the chances of neonates receiving an incorrect dose of morphine. Finally, we asked the care team about their experience of using the device to determine whether it was useful or presented problems.

The aims of the research project were to:

>develop and deploy a point-of-care morphine measuring device in a neonatal unit
>determine whether the device had a positive impact on reducing incidents involving incorrect morphine infusions
>ultimately, improve patient safety and improve practice.