Ibuprofen Care Bundle

To improve the prescribing and administration of Ibuprofen to treat the closure of Patent Ductus Arteriosus in preterm infants.

There were identified errors in prescribed and administered dosages of Ibuprofen to treat for the closure of Patent Ductus Arteriosus in preterm infants, with a lack of understanding and knowledge of side effects from both the medical trainees and nursing staff.

There was also no local or national guidance e.g. NICE had highlighted the issue as a patient safety concern.


The overall aim was to reduce the potential and incidence for medication error with the introduction of an Ibuprofen Care Bundle, in addition ensuring consistency with patient care, quality of care and patient experience.


  • To increase awareness and understanding of the complexity of Ibuprofen.
  • To reduce drug errors in prescribing and administration.
  • To model a previously successful care bundle (Gentamicin) Act as a tool for continuous audit.


Multidisciplinary approach to developing the bundle via a PDSA cycle. Changes were made after testing the document and it was marketed by informing and preparing all staff in a variety of ways.

A commencement date was set to commence use. During the PDSA audit there were no Ibuprofen errors.

There was improved knowledge and safety around the prescribing and administration of the drug.

It also improved staff knowledge and awareness of usage and side effects.

Suggestions for Further Implementation

The aim was to introduce the bundle in to other neonatal units and consider a bundle approach for other complex drugs.

Raising staff awareness was a challenge and deciding where to keep the documentation. This was undertaken as a Preceptee Service Improvement Project which helped to develop leadership skills in change management and communication.

The bundle was approved by our Local Trust and ratified through local Neonatal Governance.


Project Lead: Helen Croker/Kim Edwards

Organisation: Portsmouth Hospital NHS Trust

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