| Pharmacist (n = 26) | Pharmacy sent wrong antibiotic dose, label was right. Drug sent back to pharmacy |
| Pharmacist dispenses wrong dose of Solu-Medrol [methylpredisolone] |
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| Physician (n = 31) | [Doctor] ordered three medications patient was allergic to |
| Doctor wrote order for medication to be given IV, drug has caused fatalities when given IV |
| Clonazepam dose was too high, called to get dosage reduced |
| Doctor ordered 35 cc bolus of D10W for low chemstrip on infant weighing 1.75 kg (protocol is 2 cc/kg). |
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| Other technician or services (n = 8) | 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 |
| Nitric oxide tank empty. Respiratory therapy [sic] did not switch tanks correctly, patient without nitric oxide for 10 minutes, called respiratory therapy supervisor |
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| Registered nurse (n = 149) | Another RN took a verbal order for Tylenol 3 [paracetamol and codeine] on a patient with history of anaphylaxis to codeine |
| 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 |
| Night shift medicated patient with a med that was due at 9 am today and it is only given only 7 days, so an extra dose was given |
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| Student nurse, orientee, new staff member or agency nurse (n = 20) | New nurse had patient with SBP in the 60s and on Cardizem [diltiazem], nurse didn’t know to turn off Cardizem and start dopamine |
| 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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| Ward clerk (n = 3) | Orders for evening potassium supplements accidentally removed from Kardex by secretary |
| Incorrect order entry by unit secretary. Insulin sliding scale transcribed with wrong type of insulin |
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| Unknown (n = 130) | During a code a drip was given out of sequence |
| Under dosing of labetalol drip on hypertensive, haemorrhagic CVA patient |
| Antibiotics ordered for 24 h were transcribed wrong, resulting in extra doses |
| CT scan never done on patient |