[Medication errors resulting from drug preparation and administration].
BACKGROUND
The risks associated with drug use are not confined to adverse reactions. Failures can occur in the process of drug prescribing, dispensing and administration. Such preventable events are termed 'medication errors'. Errors in preparation and administration, the last step in the medication process, constitute a good indicator of the quality of the medication process, and are irredeemable.


METHODS
A protocol for measuring errors in the preparation and administration of medication has been developed and used in an internal medicine department at the University Hospital of Dijon.


RESULTS
This protocol has enabled several different rates of medication errors to be determined depending on the calculation approach used: 15.1% with respect to interventions by nurses, 41% relating to the total number of opportunities for error, and 8.8% with respect to a methodological problem analysed in the study. The potential clinical significance, incidence and causes of errors during the medication process were also analysed.


CONCLUSIONS
Medical errors are not detected in our health system and are thus not preventable. Their consequences are incompatible with a well organised treatment process. The rate of medication errors is therefore a good indicator of the quality of the medication system in a hospital that is following the current steps for risk reduction and accreditation.
Le Grognec
Christine
C
Service Pharmacie, CHU de Dijon, Dijon, France. c.legrognec@ch-bretagne-sud.fr
Lazzarotti
Aline
A
Marie-Joseph
Durnet-Archeray
DA
Lorcerie
Bernard
B
D004339:Drug Compounding; D064420:Drug-Related Side Effects and Adverse Reactions; D005602:France; D006801:Humans; D008508:Medication Errors; D004364:Pharmaceutical Preparations / Q000008:administration & dosage*; D012306:Risk
D004364:Pharmaceutical Preparations