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Table 3 Scenarios considered as MTE situations

From: Medication transcription errors in hospitalized patient settings: a consensual study in the Palestinian nursing practice

# Scenario Round 1 Round 2
Median IQR Median IQR
  The nurse transcribed a different item than the one prescribed or failed to transcribe a prescribed item
1 Transcribing a completely different medication; e.g. ibuprofen instead of metronidazole 9.0 0.00 na na
2 Transcribing a look-like medication; e.g. motilium instead of movalis 9.0 0.00 na na
3 Transcribing a sound-like medication; e.g. sintrom instead of centrum 9.0 1.00 na na
4 Failure to transcribe the dose of a medication that was prescribed to the patient 9.0 1.00 na na
  The nurse transcribed a different dose, frequency, dosage form or count of the prescribed item
5 Transcribing micrograms into milligrams or vice versa 9.0 2.00 na na
6 Transcribing 0.x mL into x mL or vice versa 9.0 0.25 na na
7 Transcribing x.0 mg or x.0 mL into ×0 mg or ×0 mL or vice versa 9.0 2.00 na na
8 Transcribing a dose of medication that is lower than the dose prescribed 9.0 2.00 na na
9 Transcribing a dose of medication that is higher than the dose prescribed 9.0 1.00 na na
10 Transcribing a smaller number of dose units than prescribed 8.5 2.00 na na
11 Transcribing a larger number of dose units than prescribed 9.0 1.00 na na
12 Transcribing a dosage form that is different from the one prescribed; e.g. capsules instead of suppositories or vice versa 8.0 2.00 na na
13 Transcribing a release form that is different from the one prescribed; e.g. a modified release formulation instead of conventional or vice versa 8.0 2.00 na na
14 Failure to transcribe the frequency at which the drug was prescribed to be given 9.0 1.00 na na
15 Transcribing a frequency of medication administration that is lower than the one prescribed; e.g. two times a day instead of three times a day 8.5 1.00 na na
16 Transcribing a frequency of medication administration that is higher than the one prescribed; e.g. three times a day instead of two times a day 9.0 1.00 na na
  The nurse failed to transcribe or transcribed incorrect essential information related to the prescribed item
17 Failure to transcribe prescribed instructions to administer a medication in relation to meals 7.0 4.00 7.0 2.0
18 Transcribing prescribed instructions to administer a medication before meal for a medication that was prescribed to be administered after meal or vice versa 8.0 2.00 na na
19 Failure to transcribe prescribed notes on how to administer a medication 8.0 2.00 na na
20 Failure to transcribe the prescribed the maximum daily dose of a medication that was prescribed to be administered when required 8.0 2.00 na na
21 Failure to transcribe prescribed notes pertaining to special warnings or precautions concerning the administration of a medication 8.0 2.00 na na
22 Failure to transcribe prescribed special instructions pertaining to avoiding certain foods along with the prescribed medication 8.0 2.00 na na
23 Failure to transcribe prescribed special instructions pertaining to avoiding certain drugs along with the prescribed medication 8.5 2.00 na na
24 Failure to re-transcribe a medication order in full when a change has been made to it 9.0 2.00 na na
25 Failure to transcribe prescribed instructions pertaining to when to start administering a medication 8.0 2.00 na na
26 Failure to transcribe prescribed instructions pertaining to when to stop administering a medication 8.0 2.00 na na
27 Failure to transcribe a prescribed medication 9.0 0.25 na na
28 Transcribing a medication that was not prescribed 9.0 0.25 na na
29 Transcribing a medication based on an expired medication order 9.0 1.00 na na
30 Transcribing a medication that was put on hold 8.0 2.00 na na
31 Transcribing a medication that was cancelled 9.0 1.00 na na
32 Transcribing a wrong date 8.0 2.00 na na
33 Transcribing a wrong ward 7.0 2.00 na na
34 Transcribing a wrong patient name 9.0 0.00 na na
35 Failure to transcribe prescribed special instructions pertaining to storage conditions of a medication 7.5 2.00 na na
36 Failure to transcribe prescribed instructions to use special measuring tools to measure the dose of medication to be administered 8.0 2.00 na na
37 Failure to transcribe prescribed special instructions on how to reconstitute (prepare) a medication 8.0 2.00 na na
38 Failure to transcribe prescribed special instructions to disinfect a vial before administration of a medication 8.0 2.25 8.0 1.3
39 Transcribing a route of drug administration that is different to that prescribed 9.0 1.00 na na
40 Transcribing a site of drug administration that was different to that prescribed 8.0 3.00 8.0 2.0
41 Transcribing a medication order twice 7.0 3.00 7.0 2.0
42 Transcribing a misspelled medication’s name (major), the medication can be confused with another 9.0 1.00 na na
43 Transcribing a medication order illegibly 9.0 2.00 na na
44 Transcribing a medication order using abbreviations or non-standard nomenclature 8.0 2.25 8.0 2.0
45 Failure to transcribe a prescribed duration for an intravenous infusion 8.0 2.00 na na
46 In case the prescriber made a medication order for a patient on mg/kg basis and prescribed instructions to calculate the dose, failure to transcribe the finally calculated dose of medication on the patient’s documents 7.0 5.00 7.0 2.0
47 In case the prescriber made a medication order for a patient with renal impairment and prescribed instructions to calculate the dose, failure to transcribe the finally calculated dose of medication on the patient’s documents 9.0 1.00 na na
48 Continuing to transcribe a medication for longer duration than instructed by the prescriber 8.0 2.00 na na
49 Failure to transcribe prescribed notes on the presence of other clinical conditions that might affect decisions to administer future doses of the medication prescribed to the patient 8.5 2.00 na na
50 Failure to transcribe prescribed information on the presence of allergies that might affect decisions to administer future doses of the medication prescribed to the patient 9.0 1.00 na na
51 Failure to transcribe prescribed information on contraindications that might affect decisions to administer future doses of the medication prescribed to the patient 8.0 2.00 na na
52 Failure to transcribe prescribed information on possibility of drug-drug interaction that might affect decisions to administer doses of the medication prescribed to the patient 8.0 2.00 na na
53 Failure to transcribe prescribed instructions to avoid administering certain medications along with the prescribed medication to the patient 8.0 2.00 na na
54 Failure to transcribe prescribed notes on possibility of drug-food interactions that might affect decisions to administer doses of the medication of the medication prescribed to the patient 8.0 2.00 na na
55 Failure to transcribe prescribed instructions to avoid giving the patient certain foods along with the prescribed medication 8.0 2.00 na na
56 Failure to transcribe special prescribed instructions on when to administer a medication; e.g. instructions to administer a dose of medication when the patient’s blood pressure drops below a certain limit 9.0 1.00 na na
57 Failure to transcribe special prescribed instructions on when not to administer a medication; e.g. instructions not to administer a dose of medication when the patient’s heart rate drops below a certain limit 9.0 0.25 na na
58 Failure to transcribe special prescribed instructions on monitoring the patient for certain signs before or after administering a medication; e.g. certain adverse effects 9.0 2.00 na na
59 Failure to transcribe special prescribed instructions on using appropriate diluents in the preparation of a dose of a medication 8.0 2.00 na na
60 Failure to transcribe special prescribed instructions on using appropriate solvents in the preparation of a dose of a medication 8.0 2.00 na na
61 Failure to transcribe special prescribed instructions to avoid mixing physically incompatible ingredients for the preparation of a dose of a medication 8.0 2.00 na na
62 Failure to transcribe special prescribed instructions to avoid mixing chemically incompatible ingredients for the preparation of a dose of a medication 8.0 2.00 na na
63 Failure to transcribe special prescribed instructions to avoid subjecting light-sensitive ingredients to light during the preparation of a dose of a medication 8.0 2.00 na na
64 Failure to transcribe special prescribed instructions to avoid subjecting heat-sensitive ingredients to heat during the preparation of a dose of a medication 8.0 2.00 na na
65 Failure to transcribe special prescribed instructions to follow appropriate aseptic techniques during the preparation of a dose of a medication 8.0 3.00 8.0 2.0
66 Failure to transcribe special prescribed instructions to adhere to generally followed policies of washing hands before the preparation of the medication to be administered to the patient 7.0 4.00 7.0 2.0
67 Failure to transcribe special prescribed instructions to adhere to generally followed policies of disinfecting vials before the preparation of the medication to be administered to the patient 7.0 3.00 7.0 1.0
68 Failure to transcribe special prescribed instructions to adhere to generally followed policies of shaking the suspension bottle before administering the medication to the patient 7.0 3.00 7.0 1.0
69 Failure to transcribe special prescribed instructions to ensure the administration of a sugar-free preparation of a medication to a diabetic patient 8.0 2.00 na na
  1. IQR Interquartile range, MTE Medication transcription error, na not applicable