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. 2021 Nov 24;17(3):433–440. doi: 10.1016/j.jtumed.2021.08.015

Table 2.

Frequency and examples of the different types of medication administration errors per opportunity of errors (n = 1012).

Error type Description of example Frequency Error rate (%)
Wrong Dose Levofloxacin 750 mg, nurse roughly threw half of drug solution bag (500mg/100 ml) into the sink. 18 1.78
Wrong Time Allopurinol 300 mg was administered at 3–4 PM instead of 8 AM. 84 8.3
Wrong Route Heparin was given (subcutaneous) SQ instead of IV. 1 0.01
The drug is not given A lactulose enema was not given to the patient to treat constipation associated with morphine use. 7 0.7
Incorrect drug preparation 247 24.4
  • Errors in Preparation

Bisoprolol 5 mg, nurse broke the tablet by his nails. 148 14.6
  • Wrong IV mixture

Vancomycin diluted with NS instead of SWFI. 30 2.96
  • Wrong IV volume

Micafungin 100 mg reconstituted in 10 ml NS then diluted it in 100 ml NS. 69 6.8
The incorrect technique of administration 188 18.6
  • Wrong Administration technique

The prefilled syringe of Enoxaparin was administered to the patient while the injection site was not swabbed with alcohol. 84 8.3
  • Wrong intravenous rate

Vancomycin 1250 mg constituted with 10 ml NS (instead of 20 ml SWFI) and then diluted in 100 ml NS instead of 200 ml, rate of administration = 30 min instead of 60 min 114 11.3
No documentation Pethidine given but not documented 1 0.01
Adherence error Ticagrelor tablet was left on the patient's bedside while he was sleeping, and the nurse did not verify whether the medication was taken or not. 364 35.97
Total 910 89.9

SWFI: sterile water for injection.