Table 3 Examples of medication administration errors observed
Paper or ePA prescribing | Error type (definitions based on existing work [30]) | Drug(s) involved in error | Field notes for additional context where relevant |
|---|---|---|---|
Pre-ePA (paper) | Wrong dose | 5 mg of morphine sulphate solution administered instead of 2.5 mg | The prescribed dose was “2.5 mg”. The nurse erroneously drew 2.5 ml of 10 mg/5mlsolution instead of 1.25 ml into an oral syringe. The quantity in the syringe was checked by a second nurse and a student nurse was also observing. |
Pre-ePA (paper) | Wrong dose | 312.5 mg of co-amoxiclav liquid administered instead of 625 mg | The nurse originally read the prescribed dose as “625 mg”. Then they read the concentration of co-amoxiclav on the bottle (250 mg/62.5 mg in 5 ml) and concluded that the prescribed dose actually read 62.5 mg as stated on the bottle of co-amoxiclav, not 625 mg. They informed the student nurse that the dose correlates to the smaller of the two numbers stated on the co-amoxiclav bottle (62.5 mg). Therefore 5 ml was prepared, the researcher intervened. |
Pre-ePA (paper) | Wrong dose | 12.5 mg of spironolactone administered instead of 25 mg | The original prescribed dose was 12.5 mg which had then been amended by the prescriber by scoring through the dose and re-writing “25 mg” next to the old dose. The rewritten dose was potentially unclear and interpreted as 12.5 mg. |
Post-ePA (paper) | Unintentional omission | Ramipril 2.5 mg | The nurse did not notice this drug was written on a new drug chart, the administration box was left blank. The paper chart was then transcribed to ePA and the next dose was prescribed for the following morning, so the dose was omitted. |
Post-ePA (ePA) | Wrong dose | 25 mg of metolozone administered instead of 2.5 mg | The nurse prepared five 5 mg tablets instead of cutting one tablet in half. The researcher intervened. The nurse stated that they read the dose specifically as they were not familiar with the drug. They could not see the decimal place on the computer screen and therefore read 25 mg as the dose. |
Post-ePA (ePA) | Wrong form | Venlafaxine 75 mg modified release administered instead of immediate release | The medication administered was the patient’s own, therefore it is likely that the prescription was incorrect although the nurse did not notice this. |
Post-ePA (ePA) | Wrong route | Furosemide 40 mg oral administered instead of intravenous dose | The nurse prepared oral furosemide for administration. The researcher intervened and the nurse stated that they had not noticed the route of administration. |
Post-ePA (ePA) | Wrong route | Atropine 1% eye drops administered in eyes instead of sublingually | The eye drops were being used off-label and prescribed via sublingual route although administered in each eye. The researcher intervened and the nurse stated they had not noticed the additional instructions specifying the route of administration. The researcher informed the nurse after administration to the eye. |