title: Medication errors at the administration stage in an intensive care unit.
abstract: 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.
authors.affiliation: Department of Pharmacy, University Hospital of Besançon, France.
authors.forename: E
authors.initials: E
authors.lastname: Tissot
authors.forename: C
authors.initials: C
authors.lastname: Cornette
authors.forename: P
authors.initials: P
authors.lastname: Demoly
authors.forename: M
authors.initials: M
authors.lastname: Jacquet
authors.forename: F
authors.initials: F
authors.lastname: Barale
authors.forename: G
authors.initials: G
authors.lastname: Capellier
mesh_terms: 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