Table 2 The nine different categories of medication errors
Error type | N (%) | Stories illustrating the categories |
|---|---|---|
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 |