Medication errors at the administration stage in an intensive care unit

• Published in: Intensive care medicine Vol. 25; no. 4; pp. 353 - 359
• Main Authors: TISSOT, E, CORNETTE, C, DEMOLY, P, JACQUET, M, BARALE, F, CAPELLIER, G
• Format: Journal Article
• Language: English
• Published: Heidelberg Springer 01.04.1999; Berlin Springer Nature B.V
• Subjects: Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Clinical significance; Drug administration; Drug dosages; Drug stores; Emergency and intensive care: techniques, logistics; France; Hospitals; Humans; Intensive care; Intensive care medicine; Intensive care unit. Emergency transport systems. Emergency, hospital ward; Intensive Care Units - standards; Medical errors; Medical sciences; Medication Errors; Medication Systems, Hospital - standards; Medicine; Nurses; Nursing care; Observation; Pharmacists; Prescription drugs; Prospective Studies; Quality Assurance, Health Care; France; Europe; Drug; Prevention; Quality assurance; Treatment; Error; Drug dispensation; Intensive care unit
• ISSN: 0342-4642; 1432-1238
• DOI: 10.1007/s001340050857

To assess the type, frequency and potential clinical significance of medication-administration errors. Prospective study using the observation technique as described by the American Society of HealthSystem Pharmacists but eliminating the disguised aspect. Medical intensive care unit (ICU) in a university hospital. 2009 medication administration interventions by nurses. Pharmacist-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. 132 (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. According 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.