Advances and new possibilities in neonatal care continue to astound us. Only decades ago, the arrival of surfactant revolutionized management and increased survival of the tiniest babies. Proper delivery of care has become more complex as different agencies provide new standards to reframe neonatal practices. The Joint Commission on Accreditation of Healthcare Organizations' National Patient Safety Goal #3 specifically focuses on improving the safety of using medications. Hefting even greater fiscal impact, on October 1, 2008, "the Centers for Medicare and Medicaid Services implemented a new provision within the Deficit Reduction Act 2005 which prevents payment for certain preventable errors in care.2 Its repercussions provide that hospital-acquired injuries due to preventable medication errors would not be reimbursed. Although the neonatal intensive care unit (NICU) is not usually a habitat for Medicare patients, a number of our patients are Medicaid beneficiaries, and other insurers have historically been known to use their reimbursement guidelines as a benchmark.
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