title: [Review of medication errors: a case in an intensive care unit].
abstract: OBJECTIVE
  The authors conducted for the first time a medication error review (REMED) following a medication error occurred in an intensive care unit. The aim of this study was to assess this first REMED.
  
  
  METHODS
  Descriptive study.
  
  
  METHODS
  The analysis of the medication error, consisting in the administration of Clottafact(®) instead of Aclotine(®), was performed using the REMED method.
  
  
  RESULTS
  The medication error was characterized as "proved error" and "missed before administration". Four main causes were identified: poor quality of drug storage, homophony between Aclotine(®) and Clottafact(®), non-compliance with good practices, and need of hemofiltration for the patient. At least, this REMED analysis led to the establishment of four improvements measures.
  
  
  CONCLUSIONS
  The educational aspect of the REMED was clearly appreciated by all the different health care workers who participated to the analysis. Even if medication errors may occur at the different steps of the medication process, the REMED is a very good tool to improve the care quality and also to reduce the drug iatrogenic risk.
authors.affiliation: Service de pharmacie, hôpital d'instruction des armées (HIA) Percy, 141 avenue Henri-Barbusse, Clamart, France. morgane.guillaudin@wanadoo.fr
authors.forename: M
authors.initials: M
authors.lastname: Guillaudin
authors.forename: B
authors.initials: B
authors.lastname: Debien
authors.forename: F
authors.initials: F
authors.lastname: Aouadene
authors.forename: G
authors.initials: G
authors.lastname: Camus
authors.forename: O
authors.initials: O
authors.lastname: Galvez
authors.forename: M
authors.initials: M
authors.lastname: Paillet
authors.forename: X
authors.initials: X
authors.lastname: Bohand
mesh_terms: D000991:Antithrombins / Q000627:therapeutic use*; D003221:Confusion; D004356:Drug Storage; D057915:Drug Substitution; D055695:Electronic Prescribing; D005260:Female; D005340:Fibrinogen / Q000627:therapeutic use*; D019983:Guideline Adherence; D006440:Hemofiltration / Q000451:nursing; D006772:Hospitals, Military; D006801:Humans; D007362:Intensive Care Units; D008485:Medical Audit / Q000458:organization & administration*; D008508:Medication Errors / Q000517:prevention & control; D009275:Names; D010607:Pharmacy Service, Hospital / Q000458:organization & administration; D058996:Quality Improvement; D011996:Records; D012034:Refrigeration; D012308:Risk Management; D012955:Societies, Medical; D011795:Surveys and Questionnaires; D013810:Therapeutic Equivalency
chemical_list: D000991:Antithrombins; D005340:Fibrinogen