Intensive Care Medicine

, Volume 25, Issue 4, pp 353–359

Medication errors at the administration stage in an intensive care unit

  • E. Tissot
  • C. Cornette
  • P. Demoly
  • M. Jacquet
  • F. Barale
  • G. Capellier
ORIGINAL

DOI: 10.1007/s001340050857

Cite this article as:
Tissot, E., Cornette, C., Demoly, P. et al. Intensive Care Med (1999) 25: 353. doi:10.1007/s001340050857

Abstract

Objective: To assess the type, frequency and potential clinical significance of medication-administration errors. Design: Prospective study using the observation technique as described by the American Society of Health-System Pharmacists but eliminating the disguised aspect. Setting: Medical intensive care unit (ICU) in a university hospital. Patients and participants: 2009 medication administration interventions by nurses. Interventions: 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. Measurements and results: 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. Conclusion: 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.

Key words Medication-administration error Intensive care unit Observation Quality-assurance Prevention 

Copyright information

© Springer-Verlag Berlin Heidelberg 1999

Authors and Affiliations

  • E. Tissot
    • 1
  • C. Cornette
    • 1
  • P. Demoly
    • 1
  • M. Jacquet
    • 1
  • F. Barale
    • 2
  • G. Capellier
    • 2
  1. 1.Department of Pharmacy, University Hospital of Besançon, Boulevard Fleming, F-25 030 Besançon Cedex, FranceFR
  2. 2.Department of Anesthesiology – Medical Intensive Care Unit, University Hospital of Besançon, Boulevard Fleming, F-25 030 Besançon Cedex, FranceFR

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