Table 1

Clinical and procedural medication administration error categories

Clinical errors
Error category	Error definition
Wrong drug	Drug given was not equivalent to the drug prescribed. For example: Gentamicin prepared and administered instead of erythromycin. (NB: If drug given was not similar to any ordered drug, this was recorded as an ‘unordered drug’ error instead.)
Unordered drug	Drug administered for which there was no documented order (if drug was given instead of a similar ordered drug, this was recorded as a ‘wrong drug’ error instead). For example: Heparin administered but no order for an anticoagulant.
Wrong dose	Dose of drug given was not equivalent to the dose prescribed within a margin of 10%. For example: Digoxin 250 μg ordered but three 62.5 μg tablets prepared and administered.
Extra dose	Additional dose of an ordered medication was given.
Wrong formulation	Correct drug was given but was not equivalent to the formulation prescribed. For example: MS Contin 10 mg prescribed but two plain oxycodone 5 mg tablets given.
Wrong route	Route of administration not equivalent to the route ordered. For example: Injection given intramuscularly instead of intravenously.
Wrong strength	Strength of drug given was not equivalent to the strength prescribed. For example: Entire content of ceftazidime 2 g vial prepared and administered when ceftazidime 1 g was ordered.
Wrong patient	Drug prepared for or administered to the wrong patient.
Wrong solvent/diluent (injectables)	Solvent or diluent used not recommended for use with the drug based on Australian Injectable Drugs Handbook (AIDH) or manufacturer’s guidelines (MIMS Medicines Informations handbook).
Wrong solvent/diluent volume (injectables)	Solvent or diluent volume not appropriate according to AIDH or MIMS but without a dose error.
Wrong intravenous rate	Intravenous infusion or bolus rate not appropriate according to AIDH, MIMS or hospital guidelines (>15% faster than recommended). For example: Frusemide given at 8 mg/min (policy is frusemide to be given no faster than 4 mg/min).
Incompatible drug (intravenous)	Drugs, diluents and solvents combined for intravenous infusion are not compatible according to AIDH/MIMS. For example: Cefotaxime and frusemide administered in combination.
Wrong timing	Medication administered >60 min before or after the ordered time, or >30 min before or after a meal if medication ordered to be given with meals.

Procedural errors
Procedure	Error definition
Read medication label	Nurse not observed reading the medication label.
No temporary storage	Nurse observed storing the drug temporarily in a non-secure area. For example: Medication placed on patient locker.
Check patient identification	Nurse not observed to verify that the chart matches patient identification prior to administering medication/s. For example: Nurse did not read wristband or ask the patient’s name and date of birth prior to administration.
Record medication administration	Chart not signed to indicate medication administered (or not administered with reason documented).
Check pulse and/or blood pressure	Nurse did not check the apical pulse (with stethoscope) or measure blood pressure prior to administration of digoxin.
Use aseptic technique	Gross breach of aseptic technique. For example: Did not wash hands before medication preparation; touched tablets without gloves.
Check preparation: two nurses	Medication preparation not checked by two nurses for S4, S8 and all intravenous preparations.
Check infusion pump: two nurses	Infusion rate and settings not checked by two nurses for intravenous infusions.
Witness administration: two nurses	Medication administration not witnessed by two nurses (including the administering nurse) for S4, S8 and intravenous drugs.
Drugs of dependence register: two nurses	Drugs of dependence register not signed by two nurses.