[Medication errors in hospitalised patients].
BACKGROUND
Medication errors can arise both during prescription and administration (dispensing and distribution) of drugs. Little is known about types of medication errors in Norwegian hospitals.


METHODS
All medication errors reported at St. Olav's Hospital from 1 July 2002 to 30 June 2006 were reviewed and analysed.


RESULTS
610 reports were identified. The most common cause of reporting (39 %) was prescription of a different dose from the one prescribed. Other frequent causes were administration of a different drug than the one prescribed (17 %), inadvertent subcutaneous infusion of an intravenous drug (15 %), and that the drug was given to another patient (12 %). The errors were almost exclusively reported by nurses. In 107 cases (18 %), precautions had been taken to reduce the extent of injury after the error had been identified. The causes of errors could be classified in three main categories: Nonvigilance caused by stress, lack of appropriate routines or violation of them, and lack of appropriate skills/negligence.


CONCLUSIONS
Changes of routines, improved education in existing routines, and increased pharmacological competence may contribute to prevention of medication errors.
Teigen
Ingvill Marie
IM
Avdeling for klinisk farmakologi, St. Olavs hospital, 7006 Trondheim.
Rendum
Kristin Lein
KL
Slørdal
Lars
L
Spigset
Olav
O
D000293:Adolescent; D000328:Adult; D000368:Aged; D002648:Child; D006760:Hospitalization; D006801:Humans; D008508:Medication Errors / Q000401:mortality / Q000517:prevention & control / Q000706:statistics & numerical data; D008875:Middle Aged; D009664:Norway / Q000453:epidemiology; D012308:Risk Management; D055815:Young Adult