• Ann Fr Anesth Reanim · May 2013

    Case Reports

    [Review of medication errors: a case in an intensive care unit].

    • M Guillaudin, B Debien, F Aouadene, G Camus, O Galvez, M Paillet, and X Bohand.
    • Service de pharmacie, hôpital d'instruction des armées (HIA) Percy, 141 avenue Henri-Barbusse, Clamart, France. morgane.guillaudin@wanadoo.fr
    • Ann Fr Anesth Reanim. 2013 May 1;32(5):285-90.

    ObjectiveThe 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.Study DesignDescriptive study.MethodsThe analysis of the medication error, consisting in the administration of Clottafact(®) instead of Aclotine(®), was performed using the REMED method.ResultsThe 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.ConclusionThe 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.Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.

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