Open Access Highly Accessed Research article

Evaluation of drug administration errors in a teaching hospital

Sarah Berdot12, Brigitte Sabatier13, Florence Gillaizeau4, Thibaut Caruba15, Patrice Prognon16 and Pierre Durieux2478*

Author Affiliations

1 Department of pharmacy, Hôpital européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, F-75015 Paris, France

2 INSERM, UMR S 872, Equipe 20, Centre de Recherche des Cordeliers, F-75006 Paris, France

3 INSERM, U765, F-75006 Paris, France

4 INSERM, Centre D'investigation Épidémiologique 4, F-75015 Paris, France

5 Laboratoire Interdisciplinaire de Recherche en Economie de Santé, EA4410, Université Paris Descartes, Sorbonne Paris Cité, F-75006 Paris, France

6 Université Paris-Sud 11, 92290 Chatenay-Malabry, France

7 Université Paris Descartes, Sorbonne Paris Cité, Faculté de médecine, F-75006 Paris, France

8 Department of Hospital Informatics, Hôpital européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris, 20 rue Leblanc, F-75015 Paris, France

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BMC Health Services Research 2012, 12:60  doi:10.1186/1472-6963-12-60

Published: 12 March 2012



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.


Prospective 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.


Twenty-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.


Medication administration errors are frequent. The identification of its determinants helps to undertake designed interventions.

Hospital care; Medication errors; Direct observation