Table A3.

Clinically important medication administration errors identified at observation but with no incident report

Drug name	Drug form	Error type/s	Comment
Heparin	Injection	Wrong drug Wrong dose Wrong strength	Heparin 5000 units/0.2 ml subcutaneously was ordered but enoxaparin was administered.
Metoprolol	Tablet	Wrong dose	Metoprolol 12.5 mg was ordered, nurse signed for metoprolol 25 mg but administered metoprolol 50 mg.
Tramadol	Capsule	Wrong dose Wrong formulation	Tramadol 100 mg SR was ordered but tramadol 50 mg was administered.
Gentamicin	Injection	Wrong route Wrong IV rate	Gentamicin 80 mg/2 ml administered as an IV bolus injection. Gentamicin is not recommended to be given as a bolus injection.
Irbesartan/hydrochlorothiazide	Tablet	Wrong strength Wrong dose	Irbesartan/hydrochlorothiazide 125 mg/12.5 mg 2 tablets were ordered but 300 mg/12.5 mg 2 tablets were administered.
Clopidogrel	Tablet	Extra dose	Ordered to be given Mondays, Wednesdays and Fridays. Was in addition administered, but not signed for, on a Thursday.
Ampicillin	Injection	Wrong IV rate	Recommended administration rate according to MIMS is 3–5 min. It was administered over 0.31 min.

SR, slow release; IV, intravenous; MIMS, Monthly index of medical specialties, an independent medicine information source for health care professional.