Medication errors at the administration stage in an intensive care unit.
OBJECTIVE
To assess the type, frequency and potential clinical significance of medication-administration errors.


METHODS
Prospective study using the observation technique as described by the American Society of HealthSystem Pharmacists but eliminating the disguised aspect.


METHODS
Medical intensive care unit (ICU) in a university hospital.


METHODS
2009 medication administration interventions by nurses.


METHODS
Pharmacist-performed observation of preparation and administration of medication by nurses, comparison with the original medical order and comparison with the data available in the literature.


RESULTS
132 (6.6% of 2009 observed events) errors were detected. Their distribution is as follows: 41 dose errors, 29 wrong rate, 24 wrong preparation technique, 19 physicochemical incompatibility, 10 wrong administration technique and 9 wrong time errors. No fatal errors were observed, but 26 of 132 errors were potentially life-threatening and 55 potentially significant.


CONCLUSIONS
According to this first observation-based study of medication administration errors in a European ICU, these errors were due to deficiencies in the overall organisation of the hospital medication track, in patient follow-up and in staff training.
Tissot
E
E
Department of Pharmacy, University Hospital of Besançon, France.
Cornette
C
C
Demoly
P
P
Jacquet
M
M
Barale
F
F
Capellier
G
G
D005602:France; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D008508:Medication Errors; D008510:Medication Systems, Hospital / Q000592:standards*; D019370:Observation; D011446:Prospective Studies; D011785:Quality Assurance, Health Care