Table 1. Number, Frequency, and Relationship of Discrepancies and Error Modes to Resultant Administration Errors With Subanalysis of Discrepancies With a Major Contribution to Clinically Significant and Large-Magnitude Administration Errors.
| Relationship to resultant medication administration errors | ||||||||
|---|---|---|---|---|---|---|---|---|
| Discrepancies that made a major contribution to a medication administration error | ||||||||
| HTA step at which discrepancy occurred | Error modea | Description of discrepancy | Total discrepancies (n) | No contribution n (%b) | Minor contribution n (%b) | Major contribution, total, n (%b) | Discrepancies that resulted in clinically significant errors, n (%b)c | Discrepancies that resulted in large-magnitude errors, n (%b)d |
| Overall | 44 | 23 (52%) | 5 (11%) | 16 (36%) | 6 (14%) | 4 (9%) | ||
| Find drug guide | 31 | 17 (55%) | 4 (13%) | 10 (32%) | 4 (13%) | 4 (13%) | ||
| 1.1: Access pediatric IV guide menu page | R1 | Used adult guide when pediatric guide available | 11 | 7 (64%) | — | 4 (36%) | 3 (27%) | 3 (27%) |
| R4 | Did not check IMG for guidance | 8 | 2 (25%) | — | 6 (75%) | 1 (13%) | 1 (13%) | |
| 1.2: Select correct drug from pediatric menu | A1 | > 1 minute searching for correct guide | 4 | 3 (75%) | 1 (25%) | — | — | — |
| 1.3: Access adult IV guide menu page | R4 | Did not look for an all-age guide after finding no pediatric guide available | 7 | 4 (57%) | 3 (43%) | — | — | — |
| 1.4: Select correct drug from adult menu | R1 | Failed to open all-age guide | 1 | 1 (100%) | — | — | — | — |
| Read drug guide | 13 | 6 (46%) | 1 (8%) | 6 (46%) | 2 (15%) | — | ||
| 2.2: Read method of administration | R2 | Misread method as inject aciclovir undiluted | 1 | — | — | 1 (100%) | 1 (100%) | — |
| R3 | Did not read that diluted phenytoin is “preferred” | 1 | — | — | 1 (100%) | 1 (100%) | — | |
| R4 | Information not sought | 1 | — | — | 1 (100%) | — | — | |
| 2.2.2: Read reconstitution fluid volume | R4 | Information not sought | 1 | — | — | 1 (100%) | — | — |
| 2.4: Read concentration of drug solution | A1 | > 1 minute reading time | 1 | 1 (100%) | — | — | — | — |
| R4 | Information not sought | 1 | — | — | 1 (100%) | — | — | |
| 2.5.2: Read concentration of diluted solution | A1 | > 1 minute reading time | 2 | 2 (100%) | — | — | — | — |
| R3 | Did not notice it was “maximum” dopamine concentration to dilute to | 1 | — | — | 1 (100%) | — | — | |
| 2.6.1: Read length or rate of injection | R4 | Information not sought | 1 | — | 1 (100%) | — | — | — |
| 2.6.2: Read length or rate of short infusion | A1 | > 1 minute reading time | 1 | 1 (100%) | — | — | — | — |
| R2 | Read neonatal ceftriaxone infusion time instead of infant time | 1 | 1 (100%) | — | — | — | — | |
| 2.7: Read compatibility | A1 | > 1 minute reading time | 1 | 1 (100%) | — | — | — | — |
Abbreviations: HTA, hierarchical task analysis; IMG, Injectable Medicines Guide; IV, intravenous.
Error mode codes: A1, operation took too long; R1, information not obtained; R2, wrong information obtained; R3, information retrieval incomplete; R4, information not sought.
The denominator for percentages is the total number of discrepancies in each row.
Number and percentage of clinically significant administration errors (severity score > 3), with major contributory discrepancies made at each specific step, of a total of 22 clinically significant errors identified in the original study.8
Number and percentage of large-magnitude administration errors (deviation from recommended dosing range or deviation from recommended dosing rate > 25%), with major contributory discrepancies made at each specific step, of a total of 27 large-magnitude errors identified in the original study.8
Bold faces represent totals and sub-totals of the figures which follow in subsequent rows.