|
Wrong dose
|
241 (41)
|
Due to bad communication between a nurse and an assistant nurse, they both gave a woman with diabetes insulin.
|
|
Wrong drug
|
96 (16)
|
A man with heart failure was given morphine instead of furosemide intravenously because the nurse was thinking of another patient.
|
|
Wrong patient
|
76 (13)
|
An in-patient was given drugs that were meant for the patient in the next bed.
|
|
Omission
|
69 (12)
|
A patient did not get warfarin for 2 weeks since the medication was temporarily discontinued and then forgotten.
|
|
Unauthorized drug
|
57 (10)
|
A nurse gave a patient with severe pain a higher dose of analgesics than prescribed because the lower dose had not resulted in pain relief. No physician was available at the time.
|
|
Wrong route
|
35 (6)
|
Due to a misunderstanding of the nurse’s instructions, an assistant nurse administered ear drops into the eyes of a nursing home patient.
|
|
Wrong judgement (or inadequate assessment of the patient’s need for treatment)
|
16 (3)
|
A patient who had very a low blood sugar was nevertheless given her prescribed dose of insulin.
|
|
Wrong management or storage of the drug,
|
11 (2)
|
A nurse who could not find the proper drug picked up a package from a box of discarded drugs and gave it to the patient.
|
|
Allergy-related error
|
9 (2)
|
Using the department’s the list of drugs that nurses are allowed to administer occasionally without a doctor’s order, a nurse administered alimemazine to a patient from without noticing that the patient was allergic to this drug.
|
|
Other
|
3 (<1)
| |
|
Total numbers of errors in the 585 cases
|
613
| |
