Medication errors (n = 163) | |
Wrong patient | Coworker about to give medications to wrong patient at 4 am |
| Antibiotics given to wrong patient twice, at noon and 6 pm |
Wrong drug | Dialysis technician hung wrong dialysate |
| Found lactated Ringer’s solution hanging on acute renal failure patient |
| Pharmacy sent clonidine instead of Klonopin [clonazepam] |
| [Doctor] ordered three medications patient was allergic to |
Wrong dosage | Pharmacy sent wrong antibiotic dose, label was right. Drug sent back to pharmacy |
| Found insulin drip hanging on a patient that was a different mix/ratio than had been hanging earlier, patient was receiving four times the ordered dose [of insulin] |
| Dialysis patient had received nafcillin 2 g IV q6 instead of 1 g as ordered for 3 days |
| Patient received 12 500 U bolus of heparin, patient ended up going back to OR |
| Patient with CHF to be receiving [IV] fluids at 21 cc/h, found fluids at rate of 121 cc/h when I took over care of patient at 11 pm |
Wrong route | Doctor wrote order for medication to be given IV, drug has caused fatalities when given IV |
| RN wanted to change IM phenobarbital to IVP in patient with subarachnoid bleed |
Wrong time | Scheduled mineral oil at the same time as Synthroid [levothyroxine], meds hadn’t been staggered to allow absorption |
| Post op pt was supposed to have Celebrex [celecoxib] before knee surgery—med given [after surgery] |
Omission | IV push med attached to line but not infused |
| Dose of medication scheduled for 4 pm not given, found at midnight and given |
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Procedural errors | Patient on insulin drip, blood sugars should have been obtained every hour |
| Respiratory [therapy] did not give scheduled treatment to [patient with] COPD |
| Received patient from OR, medications (Dobutrex [dobutamine] and epinephrine) not infusing, stopcock turned the wrong way |
| Someone gave a sickle cell crisis patient a tray without changing his 50% Venturi mask to nasal cannula, O2 saturation [dropped to] 69% in 15 minutes and c/o pain |
| Anesthesiologist gave Neo-Synephrine [phenylephrine] bolus for low blood pressure when the arterial line was kinked, patient’s BP was okay |
| 7:20 am found IVP/ventriculostomy was clamped and probably clamped from 11 pm to 7 am as no CSF drainage during that time and had 140 cc drainage during preceding shift |
| Speech therapy [sic] changed the angle of the head of bed on patient with ventriculostomy |
| Respiratory therapy [sic] over-stimulated closed head injury patient with suctioning, ICP into 40s, patient became bradycardic |
| Found IV infusions of isotropic agents flowing out an open stopcock onto floor |
| Nitric oxide tank empty. Respiratory therapy did not switch tanks correctly, patient without nitric oxide for 10 minutes, called respiratory therapy supervisor |
| Agency RN taking care of a patient with a blood sugar of 23, not aware of hypoglycemic protocol, waiting for [doctor] to call back, I started D50. |
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Transcription errors | Nurse did not write correct insulin order; wrote 5 U, supposed to be 15 U |
| Orders on medication administration record had added a zero to a dose of Decadron, increasing its dose 10 times more than ordered |
| Night nurse (who worked a 16-h shift) transcribed medication order incorrectly on MAR |
| Order for KCl written for today only X2, transcribed as BID |
| Incorrect order entry by unit secretary. Insulin sliding scale transcribed with wrong type of insulin |
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Charting errors | MI pt left off O2, but RN had charted that O2 was in use |
| Night RN charted wrong dose of dopamine drip, caught it at 8:15 am |
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Unable to categorise | |