Erreurs d'administrations médicamenteuses en réanimation médicale pédiatrique

Abstract

The administration act, as each step of the drugs circuit, can lead to an adverse drug event potentially harmful for the patient. The aim of this study was to highlight the adverse drug events outcoming at the administration stage and to suggest improvement elements. Errors were identified in a retrospective manner. We compared the written prescriptions (“ Prescription forms”) with the administration registration (“ Administration forms”). The differences observed between these two paper media were classified according to the errors types defined by the American Society of Hospital Pharmacists and by the American Society of Consultant Pharmacists. This study settled in the pediatric intensive care unit of a teaching hospital. We checked 1035 administrations lines: 180 errors (17,4%) were detected, including 63 omissions, 44 infusion rate errors, 42 administrations without prescription, 20 administration time errors, 7 dose errors, 2 drug form errors, 2 errors of other types, but no route of administration error. This method choice is debatable because without direct observation we could only compare what was noted to be administrated and not what was really administrated. We did not try to identify neither the causes nor the consequences of these errors on the patients. Following this study, several improvements have been set up: a new “Prescription form” (expecting the computerized prescription order entry) and reconstitution and dilution protocols for the most prescribed drugs.