Table 3. Types of medication administration errors that were detected during the postimplementation measurement observation of medication administration rounds.
Number of errors
(% of total errors)
% error occurrence per
total opportunity for error
Dose omission
86 (63%)
4.5
Over-dose
1 (0.7%)
0.05
Under-dose
8 (5.8%)
0.4
Extra dose
1 (0.7%)
0.05
Wrong strength/concentration
1 (0.7%)
0.05
Wrong drug
0
0
Wrong form
20 (15%)
1.1
Wrong technique
1 (0.7%)
0.05
Wrong time
17 (12%)
0.9
Wrong patient
2 (1.5%)
0.1
0
0
137 (100%)
7.2%
Clinical monitoring failure
TOTAL
Table 4. Examples of errors that were observed during post-implementation observation and how
they were categorised according to clinical severity
Severity of observed error
Negligible
Examples


Minor



Serious


Patient was prescribed olanzapine oro-dispersible
tablets, but was administered normal olanzapine
tablets
Citalopram prescribed to be administered at
10pm, was actually administered at 8pm
Patient prescribed 2mg of clonazepam tablets, but
was only given 1mg
Dose of folic acid that patient was due to be
administered was unintentionally omitted
Clozapine prescribed to be administered at 9am,
but was not actually administered until 2pm.
Nurse administered a medication to which the
patient had a documented severe allergy
Nurse administered sodium valproate antiepileptic medication to the wrong patient