• E Tissot, C Cornette, P Demoly, M Jacquet, F Barale, and G Capellier.
• Department of Pharmacy, University Hospital of Besançon, France.
• Intensive Care Med. 1999 Apr 1; 25 (4): 353-9.

ObjectiveTo assess the type, frequency and potential clinical significance of medication-administration errors.DesignProspective study using the observation technique as described by the American Society of HealthSystem Pharmacists but eliminating the disguised aspect.SettingMedical intensive care unit (ICU) in a university hospital.Patients And Participants2009 medication administration interventions by nurses.InterventionsPharmacist-performed observation of preparation and administration of medication by nurses, comparison with the original medical order and comparison with the data available in the literature.Measurements And Results132 (6.6% of 2009 observed events) errors were detected. Their distribution is as follows: 41 dose errors, 29 wrong rate, 24 wrong preparation technique, 19 physicochemical incompatibility, 10 wrong administration technique and 9 wrong time errors. No fatal errors were observed, but 26 of 132 errors were potentially life-threatening and 55 potentially significant.ConclusionAccording to this first observation-based study of medication administration errors in a European ICU, these errors were due to deficiencies in the overall organisation of the hospital medication track, in patient follow-up and in staff training.

12 keywords...

hide…