Medication errors at the administration stage in an intensive care unit

被引:0
作者
E. Tissot
C. Cornette
P. Demoly
M. Jacquet
F. Barale
G. Capellier
机构
[1] Department of Pharmacy,
[2] University Hospital of Besançon,undefined
[3] Boulevard Fleming,undefined
[4] F-25 030 Besançon Cedex,undefined
[5] France,undefined
[6] Department of Anesthesiology – Medical Intensive Care Unit,undefined
[7] University Hospital of Besançon,undefined
[8] Boulevard Fleming,undefined
[9] F-25 030 Besançon Cedex,undefined
[10] France,undefined
来源
Intensive Care Medicine | 1999年 / 25卷
关键词
Key words Medication-administration error; Intensive care unit; Observation; Quality-assurance; Prevention;
D O I
暂无
中图分类号
学科分类号
摘要
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.
引用
收藏
页码:353 / 359
页数:6
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