Table 1

Clinical and procedural medication administration error categories

Clinical errors
Error categoryError definition
Wrong drugDrug 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 drugDrug 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 doseDose 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 doseAdditional dose of an ordered medication was given.
Wrong formulationCorrect 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 routeRoute of administration not equivalent to the route ordered.
For example: Injection given intramuscularly instead of intravenously.
Wrong strengthStrength 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 patientDrug 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 rateIntravenous 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 timingMedication 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
ProcedureError definition
Read medication labelNurse not observed reading the medication label.
No temporary storageNurse observed storing the drug temporarily in a non-secure area.
For example: Medication placed on patient locker.
Check patient identificationNurse 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 administrationChart not signed to indicate medication administered (or not administered with reason documented).
Check pulse and/or blood pressureNurse did not check the apical pulse (with stethoscope) or measure blood pressure prior to administration of digoxin.
Use aseptic techniqueGross breach of aseptic technique.
For example: Did not wash hands before medication preparation; touched tablets without gloves.
Check preparation: two nursesMedication preparation not checked by two nurses for S4, S8 and all intravenous preparations.
Check infusion pump: two nursesInfusion rate and settings not checked by two nurses for intravenous infusions.
Witness administration: two nursesMedication administration not witnessed by two nurses (including the administering nurse) for S4, S8 and intravenous drugs.
Drugs of dependence register: two nursesDrugs of dependence register not signed by two nurses.