|Individual contributory factors||N (%)||Stories illustrating the categories.|
|Negligence, forgetfulness or lack of attentiveness||399 (68)||
One nurse put two vials on the table in a cancer patient’s home. The prescription was Hydromorphone 10 mg/ml, 1.8 ml s.c. and Morphine 10 mg/ml, 9 ml i.v. Hydromorphone is five times stronger than Morphine.
Another nurse gave an intravenous injection from a 10 ml. vial. When she was about to give Hydromorphone, that she believed existed only in 1 ml vials, she could not find it on the table. She now realized that she has given Hydromorphone instead of Morphine.
A temporarily employed doctor had prescribed ordered both Morphine and Hydromorphone in 10 ml vials.
|Proper protocol not followed||147 (25)||
A man with acute stroke had recently been treated for a myocardial infarction and was therefore admitted to the cardiology department for treatment of his stroke. He was prescribed ateplase as thrombolytic therapy. The nurse was familiar with this drug in cardiology practice but not for stroke.
Alteplase consists of two vials to be mixed by the nurse, but the dosage and the preparation are different for different diagnoses. With one of the vials in her hand, the nurse walked around and asked several doctors and nurses about the procedure. Then she mixed the ateplase infusion and administered it to the patient.
The next morning, the vial with the active ingredient was found at the table in the doctor’s office.
|Lack of knowledge||76 (13)||The same case as Proper protocol not followed.|
|Practice beyond scope of practice||68 (12)||
A nursing home patient with severe cancer pain was prescribed dextropropoxyphene and paracetamol 4 times a day and morphine 5 mg “when needed”.
On a Saturday, pain had worsened in spite of morphine 4 doses daily. The RN changes the order to paracetamol and morphine 5 mg four times daily and excluded dextropropoxphene.
The physician thought that the RN had passed her authorization when not consulting a physician.
|Inappropriate communication||62 (11)||
A nursing home patient was prescribed tramadol 1–2 tablets “when needed”. The RN put 8 tablets in a medicine cup labelled “tramadol when needed”.|
An assistant nurse with an authorization to administer drugs gave the patient all 8 tablets at the same time.
The RN had failed in her communication to the assistant nurse giving incomplete information.
|Disease or drug abuse||203 (3)||
The nurse had used the patient’s morphine herself.
The patient did not get any morphine.
|No individual factor identified||29 (5)|
|Total numbers of individual factors in the 585 cases||772|