Table 1.
Participant code | Gender | Years since qualification* | Environment at time of MAE | Type of MAE | Did the error reach the patient | Medication class | Active failure(s) |
---|---|---|---|---|---|---|---|
N01 | F | 0–4 | Ward | Wrong rate | Yes | Respiratory | Slip |
N02 | F | 5–9 | Ward | Wrong dose | Yes | Cardiovascular | KBM |
N03 | M | 0–4 | Ward | Wrong drug†‡ | Yes | Antimicrobial | Violation |
N04 | F | 0–4 | Ward | Wrong dose | Yes | Endocrine | Slip |
N05 | F | 10+ | Ward | Wrong rate | Yes | Electrolyte | Slip |
N06 | F | 0–4 | Ward | Wrong rate | Yes | Cardiovascular | KBM |
N07 | F | 5–9 | Ward | Wrong rate | Yes | Antimicrobial | KBM |
0–4 | Ward | Wrong administration technique | Yes | Cardiovascular | Lapse | ||
N08 | F | 0–4 | Ward | Wrong drug‡ | Yes | Antimicrobial | Lapse |
N09 | F | 0–4 | Ward | Wrong rate | Yes | Respiratory | Slip |
N10 | F | 0–4 | Ward | Wrong dose† | No | Cardiovascular | KBM |
N11 | M | 5–9 | Ward | Wrong drug†‡ | Yes | Antimicrobial | Violation |
N12 | F | 0–4 | Theatre | Wrong preparation§¶ | Yes | CNS | Violation (×2) |
N13 | M | 10+ | Ward | Wrong preparation | Yes | Antimicrobial | KBM |
N14 | F | 10+ | Ward | Unordered drug‡§ | Yes | Endocrine | Slip |
N15 | F | 10+ | Ward | Extra dose†‡§ | Yes | CNS | RBM |
N16 | F | 0–4 | Ward | Wrong rate | Yes | Antimicrobial | Slip |
N17 | F | 10+ | Ward | Wrong preparation¶ | Yes | Cardiovascular | Lapse |
N18 | F | 5–9 | Ward | Wrong rate | Yes | Cardiovascular | RBM |
N19 | F | 10+ | Theatre | Wrong preparation§¶ | Yes | CNS | Slip, RBM |
N20 | F | 10+ | Theatre | Wrong dose | Yes | Cardiovascular | Lapse |
*Number of years after qualified/licensed as a nurse that intravenous MAE occurred.
†Indicates occasions where nurses prepared and/or administered prescribing errors (eg, poorly written prescription).
‡Wrong drug, wrong patient, unordered drug and extra dose errors are considered ‘unauthorised drug errors’.
§Indicates occasions where a complex chain of events involving different professional groups was involved.
¶Indicates wrong label errors within wrong preparation group.
CNS, central nervous system; F, female; KBM, knowledge-based mistake; M, male; MAE, medication administration error; RBM, rule-based mistake.