Table 2.

Description of the Discrepancies That Made a Major Contribution to a Clinically Significant or Large-Magnitude Medication Administration Error.

Medicine	HTA step at which discrepancy occurred a	Error mode b	Mean severity score c	Deviation from recommended dosing range c	Deviation from recommended administration rate c	Description of related medication administration error	Description of contributory IMG-related discrepancy
Calcium chloride	1.1	R1	8.6	789%	67%	8.8 mmol given undiluted over 3 minutes rather than 0.99 mmol given diluted over 5-10 minutes	Used the adult IMG, which suggested administration of undiluted injection over 5 minutes. Pediatric IMG would have suggested diluting the injection and giving over 5-10 minutes. (Incorrect dose was based on mis-reading of the BNF)
Phenytoin	1.1	R1	7.2	—	300%	Correct dose given undiluted at 4 mg/kg/min rather than diluted at 1 mg/kg/min	Used the adult IMG, which did not state that dilution was preferred and gave a maximum infusion rate of 50 mg/min. Pediatric IMG would have stated that dilution was preferred and gave a maximum infusion rate of 1 mg/kg/min
Phenytoin	1.1	R1	6.9	—	−99%	Correct dose given too slowly (0.0078 mg/kg/min rather than 1 mg/kg/min)	Used the adult IMG, which suggested administration rate of 25 mg/min in “some patients.” Decided to give at 25 mg/min but made a calculation error when setting rate on pump. Pediatric IMG would have suggested a maximum infusion rate of 1 mg/kg/min
Lorazepam	1.1	R4	5.4	300%	High	3.2 mg given over a few seconds rather than 0.8 mg over 3-5 minutes	Did not use the IMG, which would have stated that dose should be given over 3-5 minutes
Aciclovir	2.2	R2	5.7	—	High	Correct dose given undiluted over a few seconds, rather than diluted over 1 hour	Misinterpreted the “Method of administration” section as saying that aciclovir should be given undiluted by short injection, possibly as a result of misreading “Do not administer by IV injection.” (Was also using the adult IMG, but pediatric IMG had the same wording, so this did not contribute to the error)
Phenytoin	2.2	R3	4.4	—	—	Correct dose and rate given undiluted rather than diluted	Did not notice that the “Method of administration” section in the pediatric IMG stated that diluted infusion is preferred

Abbreviations: BNF, British National Formulary; HTA, hierarchical task analysis; IMG, Injectable Medicines Guide; IV, intravenous.

^a1.1 = “Access pediatric IV guide menu page”; 2.2 = “Read method of administration.”

^bError mode codes: R1 = information not obtained; R2 = wrong information obtained; R3 = information retrieval incomplete; R4 = information not sought.

^cDerived from the original study. ⁹