Evaluation of drug administration errors in a teaching hospital

Sarah Berdot,Patrice Prognon,Pierre Durieux,Florence Gillaizeau,Brigitte Sabatier,Thibaut Caruba

doi:10.1186/1472-6963-12-60

Abstract

BackgroundMedication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors.MethodsProspective study based on disguised observation technique in four wards in a teaching hospital in Paris, France (800 beds). A pharmacist accompanied nurses and witnessed the preparation and administration of drugs to all patients during the three drug rounds on each of six days per ward. Main outcomes were number, type and clinical importance of errors and associated risk factors. Drug administration error rate was calculated with and without wrong time errors. Relationship between the occurrence of errors and potential risk factors were investigated using logistic regression models with random effects.ResultsTwenty-eight nurses caring for 108 patients were observed. Among 1501 opportunities for error, 415 administrations (430 errors) with one or more errors were detected (27.6%). There were 312 wrong time errors, ten simultaneously with another type of error, resulting in an error rate without wrong time error of 7.5% (113/1501). The most frequently administered drugs were the cardiovascular drugs (425/1501, 28.3%). The highest risks of error in a drug administration were for dermatological drugs. No potentially life-threatening errors were witnessed and 6% of errors were classified as having a serious or significant impact on patients (mainly omission). In multivariate analysis, the occurrence of errors was associated with drug administration route, drug classification (ATC) and the number of patient under the nurse's care.ConclusionMedication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

Highlights

Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration
We investigated the relationship between the occurrence of errors and potential risk factors, using logistic regression models with random effects to take multiple observations for the same patient and the same nurse into account
The highest risks of error in a drug administration were for dermatological drugs (D in ATC classification) and sensory organs drugs (S in ATC classification) but the confidence intervals were large due to small sizes

Summary

Introduction

Medication errors can occur at any of the three steps of the medication use process: prescribing, dispensing and administration. We aimed to determine the incidence, type and clinical importance of drug administration errors and to identify risk factors. Medication errors can occur during any of the three steps of the medication use process: from prescription, medication delivery to dispensing to the patient. Reviews on medication errors [2,3,4,5,6,7,8,9,10], prescription errors [11] or dispensing errors [12] are numerous. To overcome the limits described above, we aimed to assess the frequency, type, potential clinical significance and determinants of drug administration errors detected by direct observation in adult in-patients

Objectives

Methods

Results

Discussion

Conclusion