• Christine Le Grognec, Aline Lazzarotti, Durnet-Archeray Marie-Joseph, and Bernard Lorcerie.
• Service Pharmacie, CHU de Dijon, Dijon, France. c.legrognec@ch-bretagne-sud.fr
• Therapie. 2005 Jul 1;60(4):391-9.

BackgroundThe 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.MethodsA 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.ResultsThis 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.Discussion And ConclusionMedical 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.

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