Table 2.

Patient outcomes of medication errors relating to eight categories of harm (n = 3340 medication errors)

Patient outcome	n	%	Examples of patient outcome
1 Circumstances had the capacity to cause error	14	0.4	Warfarin dose not signed on drug chart
2 Error occurred, but the error did not reach the patient	618	18.5	600 mcg of naloxone was prescribed on the medication chart instead of 60 mcg – 10× overdose. Patient did not receive the dose of naloxone
3 Error occurred that reached the patient but did not cause patient harm	979	29.3	Weight recorded as 23 kg when weighed in day surgery admission; on inspection, the patient obviously weighed less than this, but issue was not detected until patient was anaesthetised and after premedication given comprising midazolam and paracetamol (acetaminophen)
4 Error occurred that reached the patient and required monitoring or intervention to confirm no harm	1631	48.8	Intravenous order for intravenous ticarcillin + clavulanic acid in emergency department but not handed over. Intravenous antibiotics commenced about 14 h late
5 Error occurred that resulted in temporary harm and required intervention	89	2.7	Noradrenaline (norepinephrine) found to be disconnected following severe hypotension and need of volume and increase of inotrope requirements following a bed turn
6 Error occurred that resulted in temporary harm and required prolonged hospitalisation	8	0.2	Patient's intravenous antibiotic, flucloxacillin, changed to oral antibiotic but continued to be given as intravenous form, delaying patient discharge
7 Error occurred that resulted in permanent patient harm	0	0	Not applicable
8 Error occurred that required intervention necessary to sustain life	1	0.1	Patient given overdose of arginine. Patient was transferred to paediatric intensive care unit for hemofiltration and treatment of the overdose