Subject(s)
Neck , Humans , Infant, Newborn , Male , Female , Clavicle , Edema/etiology , Edema/diagnosis , Diagnosis, DifferentialABSTRACT
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.
Subject(s)
Gentamicins/therapeutic use , Medical Errors , Humans , Infant, Newborn , Quality ImprovementABSTRACT
A 6-year-old girl presented acutely with worsening frontal headaches. She had a 3-month history of lethargy, reduced appetite, weight loss, cough and intermittent fevers. A chest X-ray showed a left upper lobe consolidation, and a CT head showed multiple enhancing lesions with significant surrounding oedema in both cerebral hemispheres. Due to the strong suspicion of tuberculosis (TB), she was admitted and treated with anti-TB therapy and steroids. Following this, pulmonary infection with Mycobacterium tuberculosis was confirmed by a positive PCR from induced sputum. Cerebral spinal fluid (CSF) analysis was normal and tested negative for M. tuberculosis on PCR. During her first week of treatment, she developed polyuria, nocturia and polydipsia and was diagnosed with central diabetes insipidus. She was started on desmopressin which rapidly improved her symptoms, and she was continued on desmopressin for 3 months. Currently, she remains well and has shown a good response to TB treatment.
