Table 1 Types of incidents occurring among oncology patients
Type of incidents | Site 1 (CPOE) | Site 2 (HWP) | Total | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
No. | % | Mean | 95% CI | Sig. (2-tailed) | No. | % | Mean | 95% CI | Sig. (2-tailed) | ||||
Lower | Upper | Lower | Upper | ||||||||||
Dose Omission | 5 | 0.8 | 0.01 | 0.00 | 0.02 | 0.025 | 24 | 4 | 0.04 | 0.02 | 0.05 | 0.000 | 29 |
Wrong Strength or concentration | 17 | 2.9 | 0.03 | 0.02 | 0.04 | 0.000 | 18 | 3 | 0.03 | 0.02 | 0.05 | 0.000 | 35 |
Wrong Dosage form | 42 | 7.1 | 0.07 | 0.05 | 0.09 | 0.000 | 25 | 4.1 | 0.04 | 0.03 | 0.06 | 0.000 | 67 |
Wrong route of administration | 36 | 6.1 | 0.06 | 0.04 | 0.08 | 0.000 | 4 | 0.7 | 0.01 | 0 | 0.01 | 0.000 | 40 |
Wrong time or schedule | 69 | 11.7 | 0.12 | 0.09 | 0.14 | 0.000 | 52 | 8.6 | 0.09 | 0.07 | 0.11 | 0.000 | 121 |
Wrong Rate (IV bolus/injection/infusion) | 14 | 2.4 | 0.02 | 0.01 | 0.04 | 0.000 | 28 | 4.6 | 0.05 | 0.03 | 0.07 | 0.000 | 42 |
Wrong Drug | 116 | 19.7 | 0.20 | 0.16 | 0.23 | 0.000 | 37 | 6.1 | 0.06 | 0.04 | 0.08 | 0.000 | 153 |
Wrong Technique | 19 | 3.2 | 0.03 | 0.02 | 0.05 | 0.000 | 48 | 7.9 | 0.08 | 0.06 | 0.1 | 0.000 | 67 |
Wrong Duration | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | 17 | 2.8 | 0.03 | 0.02 | 0.04 | 0.000 | 18 |
Wrong Patient | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | – | – | – | – | – | – | 1 |
Improper Dose | 185 | 31.4 | 0.31 | 0.28 | 0.35 | 0.000 | 94 | 15.5 | 0.16 | 0.13 | 0.19 | 0.000 | 279 |
Inappropriate diluents | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | 10 | 1.7 | 0.02 | 0.01 | 0.03 | 0.002 | 11 |
Inappropriate Labeling | 12 | 2 | 0.02 | 0.01 | 0.03 | 0.001 | 51 | 8.4 | 0.09 | 0.07 | 0.11 | 0.000 | 63 |
Monitoring Error (Including CIs*a and DIs*b) | 86 | 14.6 | 0.15 | 0.12 | 0.17 | 0.000 | 92 | 15.2 | 0.14 | 0.12 | 0.17 | 0.000 | 178 |
Deteriorated Drug Error | 7 | 1.2 | 0.01 | 0.00 | 0.02 | 0.008 | 1 | 0.2 | 0 | 0 | 0.01 | 0.318 | 8 |
Potential problem with the lack of treatment effectiveness | 133 | 22.6 | 0.23 | 0.19 | 0.26 | 0.000 | 53 | 8.7 | 0.08 | 0.06 | 0.1 | 0.000 | 186 |
Patient suffers or will possibly suffer from ADEs | 69 | 11.7 | 0.12 | 0.09 | 0.14 | 0.000 | 87 | 14.4 | 0.15 | 0.12 | 0.18 | 0.000 | 156 |
Drug treatment more costly than necessary | 52 | 8.8 | 0.09 | 0.07 | 0.11 | 0.000 | 109 | 18 | 0.18 | 0.14 | 0.21 | 0.000 | 161 |
Other type of incidents | 229 | 38.9 | 0.39 | 0.35 | 0.43 | 0.000 | 345 | 56.9 | 0.69 | 0.6 | 0.78 | 0.000 | 574 |
Other types (breakup) | |||||||||||||
 Unauthorized  medication | 12 | 2 | 0.02 | 0.01 | 0.03 | 0.001 | 13 | 2.1 | 0.02 | 0.01 | 0.03 | 0.000 | 25 |
 Replacing medication without approval | 6 | 1 | 0.01 | 0.00 | 0.02 | 0.014 | 1 | 0.2 | 0 | 0 | 0.01 | 0.318 | 7 |
 Requesting more than required according to order | 15 | 2.5 | 0.03 | 0.01 | 0.04 | 0.000 | 12 | 2 | 0.02 | 0.01 | 0.03 | 0.001 | 27 |
 No entry of drug administration record | – | – | – | – | – | – | 14 | 2.3 | 0.02 | 0.01 | 0.04 | 0.000 | 14 |
 Forgetting to prepare medication | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | 20 | 3.3 | 0.03 | 0.02 | 0.05 | 0.000 | 21 |
 Inappropriate storage |  |  |  |  |  |  | 6 | 1 | 0.01 | 0 | 0.02 | 0.014 | 6 |
 Not highlighting administration considerations | 33 | 5.6 | 0.00 | 0.04 | 0.07 | 0.000 | 16 | 2.6 | 0.02 | 0.01 | 0.04 | 0.000 | 49 |
 No entry of patient indication | – | – | – | – | – | – | 7 | 1.2 | 0.01 | 0 | 0.02 | 0.008 | 7 |
 Missing necessary information | 18 | 3.1 | 0.00 | 0.02 | 0.04 | 0.000 | 107 | 17.7 | 0.17 | 0.14 | 0.2 | 0.000 | 125 |
 Unnecessary or medication without need | 11 | 1.9 | 0.06 | 0.01 | 0.03 | 0.001 | 68 | 11.2 | 0.11 | 0.08 | 0.13 | 0.000 | 79 |
 Medication non-compliance | – | – | – | – | – | – | 2 | 0.3 | 0 | 0 | 0.01 | 0.157 | 2 |
 Use of abbreviations | – | – | – | – | – | – | 5 | 0.8 | 0.01 | 0 | 0.01 | 0.025 | 5 |
 Product not available | 20 | 3.4 | 0.00 | 0.02 | 0.05 | 0.000 | 24 | 4 | 0.04 | 0.02 | 0.06 | 0.000 | 44 |
 No drug given for indication | 51 | 8.7 | 0.03 | 0.06 | 0.11 | 0.000 | 33 | 5.4 | 0.06 | 0.04 | 0.08 | 0.000 | 84 |
 Therapeutic duplication | 37 | 6.3 | 0.02 | 0.04 | 0.08 | 0.000 | 20 | 3.3 | 0.03 | 0.02 | 0.05 | 0.000 | 57 |
 Entry of not administered dose in MAR*c | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | 3 | 0.5 | 0 | 0 | 0.01 | 0.083 | 4 |
 Incorrect entry in MAR*c | 1 | 0.2 | 0.00 | 0.00 | 0.01 | 0.318 | 5 | 0.8 | 0.01 | 0 | 0.02 | 0.025 | 6 |
 Wrong Indication for drug | 61 | 10.4 | 0.03 | 0.08 | 0.13 | 0.000 | 34 | 5 | 0.06 | 0.04 | 0.08 | 0.000 | 95 |
 Incorrect IV*d to PO*e conversion | 1 | 0.2 | 0.09 | 0.00 | 0.01 | 0.318 | 9 | 1.5 | 0.02 | 0.01 | 0.03 | 0.003 | 10 |
Total | 1362 | – | – | – | – | – | 1494 | – | – | – | – | – | 2856 |