Preventing medication errors.

Abstract

(1) 319 adverse effects due to errors occurring during the drug use process, as well as errors spotted before any incident, were collated in French hospitals in 2000-2001 and characterised for their type, cause, contributing factors, and consequences. (2) All stages of the drug use process were implicated in errors: prescription, transcription, preparation, dispensing, administration, and drug monitoring. (3) Dosing errors (often overdose) were the most common. (4) The main causes were poor practices and inadequate knowledge, followed by problems of communication, packaging and confusion over drug names. (5) Contributing factors included failure to follow rules and procedures, inadequate communication or training, interruptions and distractions, and drug storage on the wards. (6) The prevention of adverse effects linked to drug errors requires a commitment to record all problems, analyse them in depth, and enforce safe working practices for all health professionals.