Number, frequency and potential severity of each type of deviation
| Type of deviation | Errors | Discrepancies | |||||
| NCCMERP severity rating | n (% of 2008 infusions) | NCCMERP severity rating | n (% of 2008 infusions) | ||||
| C | D | E | A1 | A2 | |||
| Medication administration deviations | |||||||
| Rate deviation | 65 | 12 | – | 77 (3.8) | 48 | 27 | 75 (3.7) |
| Unauthorised medication | 72 | 3 | – | 75 (3.7) | – | 1 | 1 (0.0) |
| Administration start time discrepancy | 13 | – | – | 13 (0.6) | 31 | 8 | 39 (1.9) |
| Incomplete or delayed completion | 10 | – | – | 10 (0.5) | 4 | 27 | 31 (1.5) |
| Expired drug | 11 | – | – | 11 (0.5) | 1 | 1 | 2 (0.1) |
| Dose discrepancy | 5 | 2 | – | 7 (0.3) | 6 | 6 | 12 (0.6) |
| Wrong drug/fluid/diluent | 11 | – | – | 11 (0.5) | 1 | 1 | 2 (0.1) |
| Omitted medications (not administered at time of data collection) | 2 | 3 | – | 5 (0.2) | 1 | 6 | 7 (0.3) |
| Roller clamp positioned incorrectly or inappropriately | 1 | – | – | 1 (0.0) | – | 10 | 10 (0.5) |
| Concentration discrepancy | – | – | 1 | 1 (0.0) | 7 | 2 | 9 (0.4) |
| Drug library not used or incorrectly used (in the case of smart pumps) | – | – | – | – | – | 67 | 67 (3.3) |
| Allergy oversight | – | – | – | – | 2 | – | 2 (0.1) |
| All medication administration deviations | 190 | 20 | 1 | 211 | 101 | 156 | 257 |
| Procedure or documentation deviations | |||||||
| Infusion administration set not tagged/labelled correctly | – | – | – | – | – | 537 | 537 (26.8) |
| Documentation of the administration | 1 | – | – | 1 (0.0) | – | 334 | 334 (16.6) |
| Additive label missing or incorrect | 16 | 1 | – | 17 (0.8) | 2 | 200 | 202 (10.1) |
| Patient identification* | 6 | – | – | 6 (0.3) | – | 110 | 110 (5.5) |
| Documentation of the medication order | – | – | – | – | 7 | 31 | 36 (1.8) |
| All procedure or documentation deviations | 23 | 1 | – | 24 | 9 | 1212 | 1219 |
| Miscellaneous | 4 | 1 | – | 5 (0.2) | 4 | 9 | 13 (0.6) |
| All deviations | 217 | 22 | 1 | 240 | 114 | 1377 | 1491 |
*Deviations are counted per infusion; this figure includes patient identification deviations (ie, no name band) applied to all infusions for those patients. There were 88 patient identification discrepancies, counting each once per patient.
NCCMERP, National Coordinating Council for Medication Error Reporting and Prevention.