Table 2.

Examples of medication administration errors

Error type	Pre-intervention	Post-intervention
Timing error	Sertraline prescribed for 7am but not given until 8.30am	Rifaximin prescribed for administration at 7am but not given until 9.02am
Omission error	Aspirin prescribed but mistakenly omitted	Cinacalcet not in stock therefore knowingly omitted
Documentation error	Patient refused memantine but recorded as administered on the system	Gabapentin administered to a patient but nurse did not register this on the system
Wrong dose	Nurse was about to give 40 mg of furosemide but 20 mg prescribed (observer intervened)*	–
Wrong form	Modified release metformin prescribed but standard release given	–

*Although observers were blinded to the patient’s medication chart there were instances were observers visited patients on multiple occasions and therefore were aware of some of their medicines and so may have been able to intervene if they encountered an issue