Pump-programming error | First nurse programmed the pump incorrectly. Error in rate, volume or lock level. | Rate has been programmed as 0.3 ml/h. The correct rate is 3 ml/h as shown on order and label. |
Patient-identification error | Two patients in the unit have similar names and/or identifiers. The wrong patient is in the bed, or the first nurse picked up the wrong medication from pharmacy. | Order and label are for Ross Kelly, MRN (medical record number) #7004589. Patient wristband reads Kelly Ross, MRN#7004591. |
Mismatch between drug label and order | Physician changed the order after pharmacy prepared the drug, or pharmacy made a transcription error. Order is correct, but label and prepared drug are incorrect. | Order shows correct dose of 56 mg. Medication label shows 50 mg. |
Clinical decision error | Physician made error during order entry which pharmacist did not detect. All documentation elements match, but they are not clinically appropriate. Error could be in dose, volume or rate. | Physician ordered dose 10× too high. Order and label show 1000 mg. Correct clinical value is 100 mg. |