Medication error frequency by type and by site*
| Per site number of medication errors (%)* | Site A | Site B | Site C | Site D | Site E | Site F | Site G | Site H | Site I | Site J |
|---|---|---|---|---|---|---|---|---|---|---|
| Number of medications | 192 | 60 | 88 | 138 | 48 | 108 | 120 | 216 | 95 | 99 |
| Unauthorised medication | 101 (52.6) | 4 (6.7) | 5 (5.7) | 4 (2.9) | 11 (22.9) | 5 (4.6) | 17 (14.2) | 96 (44.4) | 14 (14.7) | 24 (24.2) |
| Smart pump or drug library not used | 6 (3.1) | 2 (3.3) | 33 (37.5) | 10 (9.3) | 31 (25.8) | 21 (9.7) | 4 (4.2) | 13 (13.0) | ||
| Wrong rate | 4 (2.1) | 5 (8.3) | 10 (11.4) | 3 (2.2) | 13 (12.0) | 6 (5.0) | 1 (0.5) | 4 (4.2) | 8 (8.1) | |
| Omission of intravenous fluids/medications | 4 (2.1) | 4 (6.7) | 8 (9.1) | 4 (2.9) | 1 (2.1) | 26 (24.1) | 4 (3.3) | 1 (0.5) | 2 (2.1) | |
| Expired drug | 1 (0.5) | 2 (3.3) | 3 (3.4) | 5 (3.6) | 1 (0.9) | 2 (1.7) | 1 (0.5) | 9 (9.5) | ||
| Wrong dose | 1 (0.5) | 4 (4.5) | 9 (8.3) | 2 (1.7) | 7 (7.4) | |||||
| Delay | 1 (1.7) | 3 (3.4) | 2 (1.4) | 1 (2.1) | 3 (2.8) | 1 (0.8) | 3 (3.2) | |||
| Pump setting error | 1 (0.5) | 1 (1.1) | 1 (0.5) | 2 (2.1) | 1 (1.0) | |||||
| Wrong intravenous fluids/medications | 2 (2.3) | 1 (0.8) | ||||||||
| Wrong concentration | 1 (0.9) | 1 (0.8) | 1 (1.1) | |||||||
| Patient ID error | 2 (1.0) | |||||||||
| Oversight allergy | 1 (0.5) | |||||||||
| Medication errors | 121 (63.0) | 18 (30.0) | 69 (78.4) | 8 (5.8) | 13 (27.1) | 54 (50.0) | 65 (54.2) | 71 (32.9) | 32 (33.7) | 46 (46.5) |
*Error frequency=number of errors/total number of medication administrations observed; percentages in this table do not add to 100 because some medications had more than one error.