Researchers looked at how pharmacists—medicine experts—help prevent problems with medications given to newborns in hospitals. Over three years, pharmacists caught and fixed 873 medication issues in a newborn care unit. The most common problems were wrong doses, not following hospital rules, and medicines that shouldn’t be used together. When pharmacists suggested changes, doctors agreed about 62% of the time. This study shows that having pharmacists review medications carefully can catch serious mistakes before they hurt patients, especially in delicate newborn care where even small errors matter a lot.
The Quick Take
- What they studied: How often pharmacists found medication problems in a newborn hospital unit and what types of mistakes they caught
- Who participated: 873 medication reviews done by pharmacists in a 92-bed newborn intensive care unit over 3 years (July 2022 to June 2025)
- Key finding: Pharmacists caught 873 medication problems, with wrong doses being the biggest issue (37%). Doctors accepted the pharmacist’s suggestions to fix the problem about 62% of the time
- What it means for you: Having pharmacists review medications in newborn hospitals appears to catch serious mistakes that could harm babies. This suggests hospitals should use pharmacists as part of their safety team, though more research is needed to prove it saves lives
The Research Details
Researchers reviewed records of every time a pharmacist stepped in to fix a medication problem in a newborn care unit over three years. They looked at what problems the pharmacist found, what type of medicine was involved, and whether the doctor agreed with the pharmacist’s suggestion. This is like looking back at a record book to see patterns in what went wrong and how often the fixes worked.
The study took place in one hospital unit with 92 beds for sick newborns. The pharmacists documented their work in a computer system, and researchers counted up all the problems they found and organized them by type. This method is good for understanding real-world problems but doesn’t prove that having pharmacists definitely prevents harm—it just shows what problems exist.
Newborns are extremely fragile, and even tiny mistakes with medicine can cause serious harm. Pharmacists are trained to spot medication errors that doctors might miss, like wrong doses or dangerous drug combinations. Understanding what problems happen most often helps hospitals know where to focus their safety efforts and train their staff better.
This study looked at real data from actual patient care, which is good. However, it only studied one hospital unit, so results might be different elsewhere. The study couldn’t prove that pharmacist reviews actually prevented harm to babies—it only showed that problems were caught. About 26% of the interventions had unknown outcomes, meaning researchers didn’t know if doctors actually made the changes suggested.
What the Results Show
Over three years, pharmacists documented 873 times they caught and reported medication problems. The biggest category was dosing errors—getting the amount of medicine wrong—which happened in 37% of cases (320 problems). This makes sense because newborns need very precise doses based on their tiny body weight, and even small mistakes can be dangerous.
The second most common problem was not following hospital rules about how medicines should be used (17%). The third was when a medicine was prescribed but there was no clear medical reason for it (12%). Drug interactions—when two medicines don’t work well together—happened in 8% of cases, and not checking blood tests enough happened in 5% of cases.
When pharmacists suggested fixes, doctors agreed and made changes 62% of the time. This is a good acceptance rate, suggesting doctors trust the pharmacist’s expertise. However, 26% of the time, researchers didn’t know what happened—the doctor might have agreed but didn’t document it, or the outcome wasn’t recorded.
In the most critical newborn unit (the Neonatal Intensive Care Unit), pharmacists caught 343 problems. The medicines most often involved in problems were gentamicin (an antibiotic), benzylpenicillin (another antibiotic), caffeine (used to help breathing), nutrition given through IV lines, morphine (for pain), and meropenem (an antibiotic).
The study found that certain medicines caused more problems than others. Antibiotics like gentamicin and benzylpenicillin were involved in many of the caught errors, suggesting these powerful medicines need extra careful monitoring. Caffeine, which is commonly used to help newborns breathe better, was also frequently involved in problems. This might mean doctors need more education about how to use these medicines safely in newborns.
Other studies have shown that pharmacists can prevent medication errors in hospitals, but most research focuses on adult patients. This study adds important information about newborn care, where mistakes are especially dangerous because babies can’t tell us when something is wrong. The finding that dosing errors are the most common problem matches what other research has shown—getting the right amount of medicine is consistently the hardest part of safe prescribing.
This study only looked at one hospital, so the results might not apply to other hospitals with different systems or training. The study couldn’t prove that catching these problems actually prevented harm to babies—it only showed that problems were identified. Some interventions had unknown outcomes, so we don’t know if all the pharmacist suggestions were actually used. The study also didn’t compare this hospital to hospitals without pharmacist review, so we can’t say for sure that having pharmacists makes a difference in patient safety.
The Bottom Line
Hospitals should have pharmacists review medications in newborn care units as part of their safety system (moderate confidence). Hospitals should especially focus on preventing dosing errors through better training and double-checking systems (moderate-to-high confidence). Doctors should be educated about proper use of antibiotics and other high-risk medicines in newborns (moderate confidence).
Hospital administrators and quality improvement teams should care about this research because it shows where medication problems happen most often. Doctors and nurses in newborn units should care because it highlights which medicines need extra attention. Parents of newborns in intensive care should know that having pharmacists review medications is a good safety practice. This research is less relevant to healthy newborns at home.
Changes in medication safety usually take months to show results. Hospitals might see fewer medication errors within 3-6 months of implementing pharmacist review systems, but proving that this prevents actual harm to babies would take longer studies.
Want to Apply This Research?
- If you’re a healthcare provider, track the number of medication interventions caught by pharmacists per month and the acceptance rate by prescribers. Set a goal to maintain or improve the 62% acceptance rate and investigate why 26% have unknown outcomes.
- Healthcare teams should implement a weekly meeting where pharmacists present medication problems they’ve caught, discuss patterns, and educate staff about high-risk medicines like gentamicin and benzylpenicillin. Create a simple checklist for dosing calculations in newborn care.
- Hospitals should track medication error rates monthly, categorize problems by type (dosing, interactions, monitoring), and measure how often pharmacist suggestions are accepted. Compare these numbers over time to see if the system is improving and where more training is needed.
This research describes medication problems caught in one hospital’s newborn unit and does not prove that pharmacist review prevents harm to babies. These findings should not be used to make individual medical decisions. Parents with questions about their newborn’s medications should speak with their baby’s doctor or hospital pharmacist. This study is intended for healthcare professionals and hospital administrators, not as medical advice for the general public.
This research translation is published by Gram Research, the science division of Gram, an AI-powered nutrition tracking app.