The purpose of this case study was to explain how neonatal intensive care nurses recognize and intercept medication errors. Medication errors occurring in the neonatal intensive care unit (NICU) may be more frequent when compared to other intensive care units. With nurses intercepting more errors than physicians and pharmacists, the NICU is the appropriate setting for studying medication error interception. Therefore, performing research utilizing case study techniques facilitated the understanding of how NICU nurses recognize and intercept medication errors by providing thick descriptions and themes about this safety work.

The method chosen for this investigation was the case study design utilizing multiple sources of evidence to explain the phenomenon of medication interception. The rationale for using a single case design is that this study of intercepting medication errors is assumed to be representative of NICU nurses in other NICU settings. An embedded single case design was selected because within the single case, there will be equal attention to other subunits of analysis. As it relates to medication error interception, the case study included an examination of the entire NICU in context and the embedded units of analysis which included: (a) NICU nurses experiences with medication error interception, (b) medication delivery processes, and (c) intercepted medication error data.

The sources of evidence included archival data, direct observation, interviews, and physical artifacts. Fourteen registered nurses from the NICU at the study site participated. Four key informants, a neonatologist, a neonatal nurse practitioner, a NICU nurse leader, and a clinical pharmacist contributed to the investigation.

The ethnography of critical care nurses, Clinical Wisdom and Interventions in Critical Care: A Thinking-In-Action Approach, was the suitable conceptual framework for the study of intercepted medication errors. The analysis of the interview transcripts supported the conceptual framework particularly in the practice domain, monitoring quality and managing breakdown. The NICU nurse utilized the two habits of thought in the domains of practice (a) diagnosing and managing life-sustaining functions in unstable patients (19 coded references), (b) skilled know-how of managing a crisis (41 coded references), (c) preventing hazards in a technological environment (37 coded references), and (d) monitoring quality and managing breakdown (168 coded references). A fifth domain of practice, the skilled know-how of clinical leadership and the coaching and mentoring of others, emerged as a supplementary theme.

Data obtained from archival records and interview transcripts supported the findings in the literature only in the category of the drug classification involved in the intercepted medication errors. In the literature, prescribing errors comprised the majority of the medication errors in pediatric settings. The data obtained from the archival records and interview transcript data did not support these findings. This may be due to data collection strategies employed in other studies. The data obtained from interview transcripts, direct observation, and physical artifacts supported findings in the literature pertaining to medication error preventing strategies and medication error reducing technologies. From this case study, a model emerged explaining how the information learned from mistakes evolved as cumulative wisdom in the NICU. In the presence of dangerous conditions, this cumulative wisdom facilitated the development of a culture of attentiveness.