Table 3.
Examples of each type of drug administration errors in Phase 1
| Type of error (frequency) | Examples of drug administration errors (frequency) |
|---|---|
| Incorrect administration technique (482) | – Did not flush NG tube between NG drugs and before or after adm (233) |
| – No pre-flushing prior to/after IVB/IVI adm (49) | |
| – Fast IVB – given in 10 s instead of a few minutes (50) | |
| – Did not swab injection port/site (118) | |
| – Incorrect MDI adm (8) | |
| – Did not practices contact precaution/handwash (10) | |
| Incorrect preparation (239) | – Leftover of drugs in mortar (11) |
| – Did not dilute drug prior to NG adm (24) | |
| – Did not shake extemporaneous/ready-mixed suspension (61) | |
| – Did not observe aseptic procedure when preparing IV drug (3) | |
| – Did not label the drug when more than one was prepared (16) | |
| – Did not remove bubbles in IVI/IVB prep (45) | |
| Incorrect administration time (42) | – Fluticasone given 4 h late |
| – IVI ceftriaxone given 2.5 h late | |
| – IVI benzylpenicillin given 3 h late | |
| – Paracetamol given at 14:30 h, should be at 08:00 h | |
| Incorrect dose (40) | – Carbamazepine: given 180 mg instead of 150 mg |
| – Gentamicin: increased to 40 mg but given 30 mg | |
| – Nystatin: given 1 mL instead of 0.5 mL | |
| – Erythromycin: given 800 mg instead of 500 mg | |
| – Benzylpenicillin: given 1 mL instead of 0.8 mL | |
| – Ursodeoxycholic acid: given 30 mg instead of 60 mg | |
| Deteriorated/expired drug (39) | – Frusemide (24 h expiry) given after >4 days |
| – Captopril (24 h expiry) given 2 days later | |
| Omission error (7) | – Frusemide and spironolactone not given |
| Others (2) | – Incorrect frequency |
| – IVI cloxacillin placed at inappropriate place | |
| Unauthorized drug (1) | – IVB Augmentin® (amoxicillin and clavulanate potassium) given to wrong patient |
Abbreviations: NG, nasogastric; adm, administration; IVB, intravenous bolus; IVI, intravenous infusion; s, seconds; MDI, metered-dose inhaler; h, hours.