The authors carried out a pilot study at the Jury lès Metz hospital in Metz, France. The aim was to test methods of detecting and calculating the rate of medication errors (MER) focussing on four types of MER as they were directly accessible to detection and quantification: prescribing error rate (PER), delivering error rate (DER), i.e. discrepancies between prescribed and dispensed quantities, rate of medicines missing at the time of administration rate (MMR), and the repartition error rate (RER), the rate of errors made by nurses in the repartition of medicines into trays or containers.In total 3398 prescriptions containing 15699 lines of prescription were analysed. The various mean error rates per prescription (95% confidence interval) were: Prescribing Error Rate=1.92% [1.74–2.10], Delivering Error Rate (DER)=2.7% [2.2–3.2], Missing Medication Rate=6.9% [6.1–7.7] and Picking and Repartition Error Rate=5.9% [4.4–7.4].On the basis of these results and an analysis of the literature and of a case of a fatal error which was publicized in France the authors reflect on the causes and measures for the prevention of medical errors. They conclude that in order to prevent drug induced morbidity, a systematic reduction of medication errors is needed and this requires setting up a multi-professional management quality assurance system of the drug utilization process. Furthermore, if medication errors occur they should not be covered up but analysed and remedied if possible. [ABSTRACT FROM AUTHOR]
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