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The highest error rate was detected in injections especially the intravenous route (39.58%)” al Tehewy et al (2016).


Objective: To measure the rates of medication administration errors in medical wards at Ain Shams University Hospital and to identify significant determinants of medication administration errors.

Methods: A descriptive direct-observational study of drug administration errors was carried out at medical wards of Ain Shams University hospital for a period of 3 months. A standardized observational checklist was used to observe the nurse during giving medications, and a medical record audit form was used to assess documentation. The error rates per observation, nurse, and patient were calculated, and the association between error rates and characteristics of each category was tested using linear regression to identify potential risk factors.

Results: The study included 237 patients and 28 nurses. The final number of drug administration observations was 2090 after excluding 310 omissions. A total of 5531 errors were observed with an average number of 2.67 errors per observation. More than 85% of the observations had at least one error, and the overall error rate was 37.68% (per hundred error opportunities). The highest error rate was detected in injections especially the intravenous route (39.58%). The most frequent errors were wrong documentation (90.96%) and wrong technique (78.90%), and the least was wrong patient (0.05%). The significant independent determinants of medication administration errors were high number of shifts taken by nurse per month, night shifts, weekends, elderly patient, and illiteracy.

Conclusion: Medication administration errors represent a major problem in the hospital that needs urgent intervention to optimize medication administration process. The intervention should consider the identified significant determinants of medication administration errors.


al Tehewy, M., Fahim, H., Gad, N.I., El Gafary, M. and Rahman, S.A. (2016) Medication Administration Errors in a University Hospital. Journal of Patient Safety. 12(1), p.34–39.

doi: 10.1097/PTS.0000000000000196

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