Table 1.

Examples of medication errors reported according to lex Maria and/or HSAN

ID no	Report	Drug	Where	What happened/discovered/consequences
#6	lex Maria	Cisplatin should have been cyclophosphamide	University hospital	Patient received another patient's drug, 30 mg of cisplatin instead of cyclophosphamide. Nurse discovered during further preparation and informed the doctor. The patient had to stay at hospital for 1 night. The treatment was delayed for 1 week. No permanent harm.
#16	lex Maria	Doxorubicin	Pharmacy	Pump run at too high a speed used during preparation; homepump delivered drug during 1 instead of 48 h. Discovered by patient/nurse when the infusion was so quick. Extra treatment prescribed. Probably no harm.
#18	lex Maria	Vincristine	University hospital	Dose that was 10 times higher than prescribed. A dose of 2.0 mg became 20 mg when prepared by a nurse. Discovered the same afternoon during nursing rounds; her colleagues reacted. Serious neurological harm; treated in respirator for a period. The patient died after 7 months.
	HSAN
#19	lex Maria	Cisplatin	Pharmacy	Double dose prepared. Prescription ‘Cisplatin 0.5 mg, 190 mg, 380 mL to be diluted in 2 × 1000 mL NaCl 9 mg/mL’ was interpreted as a dose of 380 mg. The first pharmacist pondered the dose in the evening, contacted the hospital and the error was discovered. Patient became deaf.
	HSAN
#40	HSAN	Etoposide	University hospital	Total dose for the course became dose per day, 330 mg, 3 times per day for 3 days, should have been 110 mg, 3 times per day for 3 days. Nurse suspected that the dose was too high and treatment was not given on day 3. Patient suffered from anaemia and was hospitalised for two weeks.
#53	lex Maria	Carboplatin	County hospital	Prescription for 5 days should have been only for 1 day. Due to hearing disturbances from cisplatin, there was a switch to carboplatin. Dose 800 mg per day. Discovered when the patient came back with adverse reactions, hospitalised for a week. Probably no long-term harm.