Pharmacy World and Science

, Volume 25, Issue 6, pp 264–268 | Cite as

Observational study of potential risk factors of medication administration errors

  • Edgar Tissot
  • Christian Cornette
  • Samuel Limat
  • Jean-Louis Mourand
  • Michèle Becker
  • Joseph-Philippe Etievent
  • Jean-Louis Dupond
  • Micheline Jacquet
  • Marie-Christine Woronoff-Lemsi

Abstract

Objective: Medication administration errors (MAEs) are the second most frequent type of medication errors, as has been shown in different studies in the literature. The aims of this observational study were to assess the rate and the potential clinical significance of MAEs and to determine the associated risk factors. Design: In two departments, Geriatric Unit (GU) and Cardiovascular-Thoracic Surgery Unit (CTSU) of Besançon University Hospital (France), MAEs were identified using the undisguised observation technique and classified according to the definitions of the American Society of Health-System Pharmacists. Injectable administration, lack of nurses's standardized protocol for the preparation and administration of drugs, incomplete or illegible prescription and nurse's workload were analysed as potential risk factors of MAEs in multivariate logistic regression analysis.Results: During a period of 20 days, opportunities for error concerning 56 patients and 78 MAEs (58 in CTSU and 26 in GU) were observed. The medication administration error rate was 14.9%. Dose errors were the most frequent (41%) errors, followed by wrong time (26%) and wrong rate errors (19%). No potential fatal errors were observed, 8 (10%) were estimated as potentially life-threatening, 20 (26%) potentially significant and 50 (64%) potentially minor. Nurse workload and incomplete or illegible prescriptions were two independent risk factors of MAEs.Conclusion: According to these data, the quality of the medication administration process needs to be optimized in hospitals in order to minimize the incidence of iatrogenic preventable diseases.

Administration France Iatrogenic disease Medication error Observation Pharmacy Prevention Risk factor 

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References

  1. 1.
    Kohn LT, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC: National Academy Press, 2000.Google Scholar
  2. 2.
    ASHP Reports. Suggested definitions and relationships among medication misadventures, medication errors, adverse drug events, and adverse drug reactions. Am J Health Syst Pharm 1998; 55: 165–166.Google Scholar
  3. 3.
    Schmitt E. Unit-dose drug distribution systems: old-fashioned or safer ways for pharmaceutical care ? Eur Hosp Pharm 2000; 6(1): 4–12.Google Scholar
  4. 4.
    Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi D et al. Incidence of adverse drug events and potential adverse drug events. JAMA 1995; 274(1):29–34.Google Scholar
  5. 5.
    Kaushal R, Bates DW, Landrigan C, McKenna KJ, Clapp MD, Federico F et al. Medication errors and adverse drug events in pediatric inpatients. JAMA 2001; 285(16): 2114–20.Google Scholar
  6. 6.
    Barker KN. Data collection techniques: observation. Am J Hosp Pharm 1980; 37: 1235–43.Google Scholar
  7. 7.
    Allan EL, Barker KN. Fundamentals of medication error research. Am J Hosp Pharm 1990; 47: 555–71.Google Scholar
  8. 8.
    Tissot E, Cornette C, Demoly P, Jacquet M, Barale F, Capellier G. Medication errors at the administration stage in an intensive care unit. Intensive Care Med 1999; 25(4): 353–9.Google Scholar
  9. 9.
    Van Den Bemt PM, Fijn R, Van Der Voort PH, Gossen AA, Egberts TC, Brouwers JR. Frenquency and determinants of drug administration errors in the intensive care unit. Crit Care Med 2002; 30: 846–50.Google Scholar
  10. 10.
    Schneider MP, Cotting J, Pannatier A. Evaluation of nurses' errors associated in the preparation and administration of medication in a pediatric intensive care unit. Pharm World Sci 1998; 20(4): 178–82.Google Scholar
  11. 11.
    O'Hare M, Bradley A, Gallacher T, Shields M. Errors in administration of intravenous drugs. BMJ 1995; 310: 1536–37.Google Scholar
  12. 12.
    Lacasa C, Cot R, Roure C, Martinez J, Polo C, Andreu C et al. Medication errors in a general hospital. Eur Hosp Pharm 1998; 4(2): 35–40.Google Scholar
  13. 13.
    Taxis K, Dean B, Barber N. Hospital drug distribution systems in the UK and Germany - a study of medication errors. Pharm World Sci 1999; 21(1): 25–31.Google Scholar
  14. 14.
    Dean BS, Allan EL, Barber ND, Barker KN. Comparison of medication errors in an American and a British hospital. Am J Health Syst Pharm 1995; 52: 2543–49.Google Scholar
  15. 15.
    Barker KN, McConnell WE. The problems of detecting medication errors in hospitals. Am J Hosp Pharm 1962; 19: 361–9.Google Scholar
  16. 16.
    Martindale: the complete drug reference. 33rd ed. London: Pharmaceutical Press 2002.Google Scholar
  17. 17.
    Trissel LA. Handbook on injectable drugs. 9th ed. Bethesda, Maryland: American Society of Health-System Pharmacists Office, 1996.Google Scholar
  18. 18.
    ASHP Report. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm 1993; 50: 305–14.Google Scholar
  19. 19.
    Folli H, Poole R, Benitz W, Russo J. Medication error prevention by clinical pharmacists in two children's hospitals. Pediatrics 1987; 79: 718–22.Google Scholar
  20. 20.
    Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm 2002; 59: 436–46.Google Scholar
  21. 21.
    Dean BS, Barber ND. Validity and reliability of observational methods for studying medication administration errors. Am J Health Syst Pharm 2001; 58(1): 54–9.Google Scholar
  22. 22.
    Foster C. Why do research ethics committees disagree with each other. J R Coll Phys Lond 1995; 29: 315–8.Google Scholar
  23. 23.
    Tissot E, Cornette C, Capellier G, Schmitt E. Assessment of medication errors: methodological details. Intensive Care Med 1999; 25: 1478.Google Scholar
  24. 24.
    Bates DW, Boyle DL, Vander Vliet MB, Schneider J, Leape L. Relationship between medication errors and adverse drug events. J Gen Intern Med 1995; 10:199–205.Google Scholar
  25. 25.
    Phillips J, Beam S, Brinker A, Holquist C, Honig P Lee LY et al. Retrospective analysis of mortalities associated with medication errors. Am J Health Syst Pharm 2001; 58(19): 1824–9.Google Scholar
  26. 26.
    Bond CA, Raehi CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy 2001; 21(9): 1023–36.Google Scholar
  27. 27.
    Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. Hospital mortality in relation to staff workload: a 4–years study in an adult intensive-care unit. Lancet 2000; 356: 185–89.Google Scholar
  28. 28.
    Osborne J, Blais K, Hayes JS. Nurses' perception: when is it a medication error? JONA 1999; 29(4): 33–8.Google Scholar
  29. 29.
    Leape LL, Bates DW, Cullen DJ, Cooper J, Demonaco HJ, Gallivan T et al. Systems analysis of adverse drug events. JAMA 1995; 274(1): 35–43.Google Scholar
  30. 30.
    Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. JAMA 1990; 263(17): 2329–34.Google Scholar
  31. 31.
    Mohseni I, Wong DH. Medication erors analysis is an opportunity to improve practice. Am J Surg 1998; 175: 4–9Google Scholar
  32. 32.
    Raschke RA, Gollihare B, Wunderlich TA, Guidry JR, Leibowitz AI, Peirce JC et al. A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital. JAMA 1998; 280(15): 1317–20.Google Scholar
  33. 33.
    Bates DW, Teich JM, Lee J, Seger D, Kuperman GJ, Ma'Luf N et al. The impact of computerized physician order entry on medication error prevention. JAMIA 1999; 6(4): 313–21.Google Scholar
  34. 34.
    Evans RS, Pestotnik SL, Classen DC, Clemmer TP, Weaver LK, Orme JF et al. A computer-assisted management program for antibiotics and other antiinfective agents. N Engl J Med 1998; 338: 232–8.Google Scholar
  35. 35.
    Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI et al. Pharmacist participation on physician rounds and adverse drug events in the intensive care unit. JAMA 1999; 282(3): 267–70.Google Scholar

Copyright information

© Kluwer Academic Publishers 2003

Authors and Affiliations

  • Edgar Tissot
    • 1
  • Christian Cornette
    • 1
  • Samuel Limat
    • 1
  • Jean-Louis Mourand
    • 2
  • Michèle Becker
    • 3
  • Joseph-Philippe Etievent
    • 2
  • Jean-Louis Dupond
    • 3
  • Micheline Jacquet
    • 1
  • Marie-Christine Woronoff-Lemsi
    • 1
  1. 1.Pharmacy DepartmentBesançon University Hospital, Boulevard FlemingBesançon CedexFrance
  2. 2.Cardiovascular-Thoracic Surgery DepartmentBesançon University Hospital, Boulevard FlemingBesançon CedexFrance
  3. 3.Geriatric DepartmentBesançon University Hospital, Boulevard FlemingBesançon CedexFrance

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