Total error frequency, type and potential severity rating
| Type of error | Total number of errors | Error frequency (%)* | NCC MERP severity rating | ||||
|---|---|---|---|---|---|---|---|
| Number of patients=478, Number of medications=1164 | E | D | C | B | A | ||
| Label not complete according to policy† | 699 | 60.1 | 609 | 8 | 82 | ||
| Tubing not tagged according to policy† | 407 | 35.0 | 375 | 1 | 31 | ||
| Unauthorised medication | 281 | 24.1 | 230 | 1 | 50 | ||
| Smart pump or drug library not used | 120 | 10.3 | 112 | 4 | 4 | ||
| Wrong rate | 54 | 4.6 | 2 | 49 | 3 | ||
| Omission of intravenous fluids/medications | 54 | 4.6 | 1 | 33 | 20 | ||
| Expired drug | 24 | 2.1 | 1 | 20 | 1 | 2 | |
| Wrong dose | 23 | 2.0 | 20 | 1 | 2 | ||
| Delay | 14 | 1.2 | 1 | 13 | |||
| Pump setting error | 6 | 0.5 | 6 | ||||
| Wrong intravenous fluids/medications | 3 | 0.3 | 3 | ||||
| Wrong concentration | 3 | 0.3 | 3 | ||||
| Patient ID error | 2 | 0.2 | 2 | ||||
| Oversight allergy | 1 | 0.1 | 1 | ||||
| All errors | 1691 | 145.3 | 1 | 4 | 1476 | 16 | 194 |
| Policy violation errors | 1106 | 95.0 | 984 | 9 | 113 | ||
| Medication errors | 497 | 42.7 | 1 | 4 | 492 | ||
*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.
†Policy violation error.
NCC MERP, National Coordinating Council for Medication Error Reporting and Prevention.