Types of policy deviations* | N | Examples and descriptions | Potential medication errors |
Medication not dispensed; obtained and given during observation | 55 | Nurse did not check for omission of dispensing before administration round start even though some medications (eg, parenteral injectables) were not expected to be found in the COW at all | Omission |
Medication not dispensed; not given during observation† | 25 | ||
Barcode label missing | 70 | Dispensed tablets without a barcode label, or without primary packaging | Wrong medication Wrong dose |
Wrong dose dispensed† | 30 | Dispensed whole blister pack instead of one tablet (correct dose) | Wrong dose |
Scanning failure | 26 | Barcode on the medication was not readable for the scanner | Wrong medication Wrong dose Wrong route |
Barcode label not attached | 13 | Barcode label was in the patient drawer but not attached to the medication Nurses stored expired labels for future administrations to save time from printing new labels | Wrong medication |
Wrong medication dispensed† | 11 | Dispensed extended-release tablet instead of tablet Dispensed sound-alike medication, for example, Lescol instead of Losec Dispensed 2 g Cloxacillin intravenous bag from the storage room instead of 1 g Errors discovered by scanning in eMAR | Wrong medication |
COW deviations due to recent changes in the eMAR | 7 | Antithrombotic medication was dispensed in the patient drawer, nurse removed it during administration due to the patient being scheduled for surgery that day | Contraindication Wrong drug Wrong route |
Medication placed in the wrong compartment in the drawer | 5 | During dispensing, medication prescribed for morning administration was placed in the compartment in the patient drawer assigned for evening administration | Wrong medication Omission or wrong time |
Wrong room number on patient drawer | 3 | The patient changed the room, but the room number on the patient drawer was not changed | Wrong patient |
Wrong label attached | 1 | Attached ‘metoprolol’ label on a generic substitute Bloxazoc (metoprolol) unit dose. Revealed after failure with scanning the label | Wrong medication Wrong dose |
Patients’ own medication stored in the patient room | 24 | We observed deviation of this policy for 24 of total 25 patients’ own medications (96%) | Wrong dose Wrong medication |
*The number of deviations refers to one deviation of the same type per patient even if more deviations of same type exist with one patient, for example, if one patient had wrong dose dispensed for two medications, this was counted as one deviation.
†Deviations which also classify as actual medication errors.
COW, computer on wheels; eMAR, electronic Medication Administration Record.