Adverse drug reactions and medication errors: the place of the organization of drugs distribution

The true incidence of adverse drug events is controversial and there are fe w data concerning the percentage of potentially preventable adverse drug ev ents. Over 2 months, in two internal medicine units, we asked the staff to report adverse drug events. All incidents were evaluated: adverse drug even ts (preventable and nonpreventable) and potential adverse drug events (non- intercepted potential adverse drug events and intercepted potential adverse drug events). The severity, the stage in the process at which the error oc curred and the type of error were evaluated by a physician reviewer. Over t he 240 admissions, the incidence of adverse drug events is 18 per 1000 pati ent-days. The system design caused 77 per cent of the incidents. The medica tion errors occurred at all stages from ordering to administration. Adverse drug events resulting in medication errors (n = 22) were more serious than non-preventable adverse drug events (n = 26)(p = 0.003). A prevention stra tegy by pharmacovigilance centres (Centres Regionaux de Pharmacovigilance) should target all stages of the drug delivery process.