Table 4.
Type and potential severity of medication administration errors (MAEs) before and after implementation of central automated unit dose dispensing and barcode-assisted medication administration
| Pre-intervention | Post-intervention | |
|---|---|---|
| Included medication administrations, n | 1490 | 1630 |
| MAEs, n | 316 | 272 |
| Type of MAE, n (% of administrations) | ||
| Wrong administration technique | 78 | 99 |
| Too fast administration | 51 (3.4) | 83 (5.1) |
| Incompatibility of parenteral medication | 21 (1.4) | 3 (0.2) |
| Other | 6 (0.4) | 13 (0.8) |
| Wrong medication handling | 57 (3.8) | 59 (3.6) |
| Omission | 68 (4.6) | 33 (2.0) |
| Wrong dose | 57 (3.8) | 35 (2.1) |
| Unordered drug | 25 (1.7) | 26 (1.6) |
| Wrong dosage form | 25 (1.7) | 20 (1.2) |
| Wrong route of administration | 5 (0.3) | 0 |
| Expired medication | 0 | 0 |
| Other | 1 (0.1) | 0 |
| Potential severity of MAEsa, n (% of administrations) | ||
| Error, no harm | ||
| C | 173 (11.6) | 209 (12.8) |
| D | 99 (6.6) | 58 (3.6) |
| Error, harm | ||
| E | 35 (2.3) | 5 (0.3) |
| F | 7 (0.5) | 0 |
| H | 2 (0.1) | 0 |
NCC MERP classification [24]: no error (category A); error, no harm (category B to D); error, harm (category E to H); and error, death (category I). C: an error occurred that reached the patient but did not cause patient harm; D: an error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm; E: an error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention; F: an error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization; H: an error occurred that required intervention necessary to sustain life.