title: Observational study of potential risk factors of medication administration errors.
abstract: 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.
authors.affiliation: Pharmacy Department, Besançon University Hospital, Boulevard Fleming, 25030 Besançon, France.
authors.forename: Edgar
authors.initials: E
authors.lastname: Tissot
authors.forename: Christian
authors.initials: C
authors.lastname: Cornette
authors.forename: Samuel
authors.initials: S
authors.lastname: Limat
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Mourand
authors.forename: Michële
authors.initials: M
authors.lastname: Becker
authors.forename: Joseph-Philippe
authors.initials: JP
authors.lastname: Etievent
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Dupond
authors.forename: Micheline
authors.initials: M
authors.lastname: Jacquet
authors.forename: Marie-Christine
authors.initials: MC
authors.lastname: Woronoff-Lemsi
mesh_terms: 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
chemical_list: D004364:Pharmaceutical Preparations