Observational study of potential risk factors of medication administration errors.
OBJECTIVE
Medication administration errors (MAEs) are the second most frequent type of medication errors, as has been shown in different studies in the literature. The aims of this observational study were to assess the rate and the potential clinical significance of MAEs and to determine the associated risk factors.


METHODS
In two departments, Geriatric Unit (GU) and Cardiovascular-Thoracic Surgery Unit (CTSU) of Besançon University Hospital (France), MAEs were identified using the undisguised observation technique and classified according to the definitions of the American Society of Health-System Pharmacists. Injectable administration, lack of nurses's standardized protocol for the preparation and administration of drugs, incomplete or illegible prescription and nurse's workload were analysed as potential risk factors of MAEs in multivariate logistic regression analysis.


RESULTS
During a period of 20 days, opportunities for error concerning 56 patients and 78 MAEs (58 in CTSU and 26 in GU) were observed. The medication administration error rate was 14.9%. Dose errors were the most frequent (41%) errors, followed by wrong time (26%) and wrong rate errors (1996). No potential fatal errors were observed, 8 (10%) were estimated as potentially life-threatening, 20 (26%) potentially significant and 50 (64%) potentially minor. Nurse workload and incomplete or illegible prescriptions were two independent risk factors of MAEs.


CONCLUSIONS
According to these data, the quality of the medication administration process needs to be optimized in hospitals in order to minimize the incidence of iatrogenic preventable diseases.
Tissot
Edgar
E
Pharmacy Department, Besançon University Hospital, Boulevard Fleming, 25030 Besançon, France.
Cornette
Christian
C
Limat
Samuel
S
Mourand
Jean-Louis
JL
Becker
Michële
M
Etievent
Joseph-Philippe
JP
Dupond
Jean-Louis
JL
Jacquet
Micheline
M
Woronoff-Lemsi
Marie-Christine
MC
D000368:Aged; D011307:Drug Prescriptions; D006785:Hospitals, University; D006801:Humans; D008508:Medication Errors / Q000379:methods*; D008510:Medication Systems, Hospital / Q000458:organization & administration; D019370:Observation; D004364:Pharmaceutical Preparations / Q000008:administration & dosage*; D011446:Prospective Studies; D011785:Quality Assurance, Health Care / Q000379:methods / Q000458:organization & administration; D012306:Risk
D004364:Pharmaceutical Preparations