Table 2

Errors used in laboratory experiment

Error typeExplanationExample
Pump-programming errorFirst 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 errorTwo 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 orderPhysician 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 errorPhysician 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.