Background Medication administration traceability allows us to know exactly which drugs were effectively taken by the patient. The accuracy of the information is essential to assess treatment efficacy or to analyse adverse drug reactions. However, an injection falsely traced as administered was observed in our hospital, implying the traceability was noted before the act of administration.

Purpose To review when the medication administration is traced in our hospital.

Material and methods A 2 week prospective clinical audit was conducted by 16 nurses in 10 clinical units. Three 45 min periods of observations per clinical unit were allocated among the different administration times (morning, 10am–noon; evening, noon–4pm). Data collected included: administration route, if the medication was effectively administered or not and when the information was recorded (in real time, before or after the administration, untraced). Data were analysed by a pharmacist. Only administrations traced in real time were analysed.

Results 342 observations were analysed (from 5 in paediatrics to 102 in pneumology). 106 (31%) administrations were registered before the medication intake and 20 (6%) after. In 5 clinical units, almost all of the administrations were traced in real time. In pneumology and geriatrics, administrations were registered mostly before drugs intake. In obstetrics, 5 of 7 administrations (71%) were traced a posteriori. In the emergency room, all situations were encountered: 10 (48%) in real time, 7 (33%) before and 4 (19%) after the administration. 70% of drugs administered in the morning were traced a priori (80 on 114). However, 89 (78%) morning observations were provided by pneumology and geriatrics. 39% of the traceability of oral drugs was recorded before the act of administration (102 of 260). For 62 drug injections (intravenous and subcutaneous), 55 (89%) administrations were traced in real time.

Conclusion 61% of observations met the criteria. The rate of traceability recorded before the act of administration was too high and was mostly clinical unit dependent. The results were transmitted to the units and the medication administration rules were promoted (poster, professional training). To evaluate the measures taken, a new audit will be conducted.

References and/or acknowledgements Thanks to Charline Deschamps, Anthony Hervé and the auditors.

No conflict of interest