Case report : contexte sanitaire Covid-19, un risque supplémentaire d’erreur médicamenteuse ?

INTRODUCTION: A medication error occurred in a recently reorganized hospital department as a result of the Covid-19 outbreak. CASE REPORT: Case of a patient who received a treatment not intended for him, with no clinical consequence. The objective of our study is to identify and analyse the causes of this adverse event. METHODS: The error was reported internally and a post systemic analysis using the REMED method was performed. RESULTS: The analysis of the medication error revealed several contributing factors, including the recent reorganization of the service following the health context. DISCUSSION: Medication error may be due to the systemic organization of the patient's medication management process: factors related to the patient, organization and management, operational practices and procedures, and the healthcare professional. CONCLUSION: Among the improvement actions a review of the location of the pharmacy within the department, a transport of patients with reduced mobility to it for the administration of treatments and a reminder to registered nurses to deblister pharmaceuticals at the time of administration were proposed.