Background
Methods
Design and setting
Description of the data
Data analysis
Text parsing and filtering
Concept linking
Clustering
Weights between medications and highly associated terms
Results
Data characteristics
Characteristics | No. | % |
---|---|---|
Severity | ||
No harm | 62,461 | 86.3 |
Low | 9,147 | 12.6 |
Moderate | 708 | 1.0 |
Death | 46 | 0.1 |
Error type | ||
Omitted medicine / ingredient | 19,815 | 27.4 |
Other | 12,528 | 17.3 |
Wrong frequency | 6,975 | 9.6 |
Wrong drug | 5,494 | 7.6 |
Wrong /unclear dose or strength | 5,187 | 7.2 |
Wrong quantity | 4,415 | 6.1 |
Mismatching between patient and medicine | 3,437 | 4.7 |
Wrong storage | 2,091 | 2.9 |
Wrong method of preparation / supply | 2,001 | 2.8 |
Wrong route | 1,715 | 2.4 |
Adverse drug reaction (when used as intended) | 1,584 | 2.2 |
Wrong / omitted / passed expiry date | 1,458 | 2.0 |
Wrong formulation | 1,256 | 1.7 |
Patient allergic to treatment | 1,248 | 1.7 |
Unknown | 1,131 | 1.6 |
Contra-indication to the use of the medicine in relation to drugs or conditions | 1,079 | 1.5 |
Wrong / transposed / omitted medicine label | 505 | 0.7 |
Wrong /omitted verbal patient directions | 406 | 0.6 |
Wrong / omitted patient information leaflet | 65 | 0.1 |
Location | ||
Ward | 47,149 | 65.1 |
Intensive care unit / high dependency unit | 5,034 | 7.0 |
Operating theatre | 1,480 | 2.0 |
Pharmacy | 1,423 | 2.0 |
Hospital buildings (inside) | 1,299 | 1.8 |
Other | 944 | 1.4 |
Radiology | 449 | 0.6 |
Recovery room | 315 | 0.4 |
Anaesthetic room | 237 | 0.3 |
Missing information | 14,060 | 19.4 |
TOTAL | 72,390 | 100 |
Drug | Freq. | |
---|---|---|
1. | insulin | 2577 |
2. | morphine | 2541 |
3. | paracetamol | 2155 |
4. | sodium / sodium chloride | 1755 |
5. | oxycodone | 1429 |
6. | co-amoxiclav | 1039 |
7. | potassium / potassium chloride | 1032 |
8. | unknown | 1019 |
9. | chloride | 974 |
10. | enoxaparin | 970 |
11. | fentanyl | 880 |
12. | gentamicin | 853 |
13. | dalteparin | 852 |
14. | sulphate | 783 |
15. | furosemide | 652 |
16. | Tazocin [piperacillin / tezobactam] | 631 |
17. | warfarin | 542 |
18. | glucose | 521 |
19. | heparin | 419 |
20. | vancomycin | 413 |
21. | aspirin | 353 |
22. | tramadol | 350 |
23. | dexamethasone | 338 |
24. | flucloxacillin | 336 |
25. | ibuprofen | 324 |
26. | codeine | 291 |
27. | midazolam | 287 |
28. | benzylpenicillin | 284 |
29. | saline | 271 |
30. | nutrition | 267 |
Medications related to incidents and highly associated terms
Drug | Freq. | Docs | Highly associated terms based on concept linking |
---|---|---|---|
insulin | 10,086 | 4214 | unit, time, level, morning, administer, evening, visit, nurse |
antibiotic | 6280 | 4313 | sepsis, due, allergic, time, night, dose, ward, cannula |
paracetamol | 5449 | 3071 | relief, pain, pain relief, child, hour, dose, orally, theatre |
morphine | 4194 | 2244 | syringe, analgesia, pump, book, relief, pain, pain relief, check |
saline | 2676 | 1848 | water, dilute, label, commence, check, arm, contrast, cannula, ctpa [CT pulmonary angiography] |
oxycodone | 2666 | 1521 | morphine, balance, book, tablet, pain, bottle, check, immediate, prn |
warfarin | 2319 | 1151 | valve, tinzaparin, INR, clinic, result, yellow, dose, patient warfarin |
glucose | 2138 | 1445 | pump, saline, high, infusion, unit, level, commence, check, insulin |
gentamicin | 2098 | 1180 | intravenous, benzylpenicillin, metronidazole, antibiotic, sepsis, due, hour, dose, level |
chemotherapy | 2052 | 1355 | flush, bag, day, trial, unit, treatment, commence, first, line |
amoxicillin | 2031 | 1455 | intravenous, oral, wrist, rash, reaction, metronidazole, allergy, antibiotic, allergic |
fentanyl | 1843 | 1193 | anaesthetist, syringe, book, pain, find, old, check, patch, theatre |
dalteparin | 1829 | 1128 | prophylactic, INR, pulmonary, sign, prophylaxis, warfarin, risk, unit, injection |
potassium | 1728 | 921 | fluid, magnesium, pump, saline, high, infusion, level, commence |
oramorph | 1726 | 1145 | morphine, amount, analgesia, book, relief, pain, pain relief, bottle, prn |
furosemide | 1568 | 984 | run, heart, intravenous, rate, pump, hour, infusion |
penicillin | 1453 | 929 | benzylpenicillin, wrist, rash, reaction, allergy, antibiotic, sepsis, allergic, know |
intravenous antibiotic | 1419 | 1224 | midwife, baby, intravenous, cannulation, benzylpenicillin, antibiotic, sepsis, due, cannula |
Clexane [enoxaparin] | 1404 | 848 | prophylactic, sign, warfarin, therapeutic Clexane [enoxaparin], treatment dose, therapeutic, injection |
sodium | 1401 | 1031 | glucose, arterial, transducer, bag, fluid, potassium, phosphate, infusion, dilute |
vancomycin | 1364 | 751 | difficile, continuous infusion, loading, intravenous, continuous, infusion, dose, level |
dextrose | 1233 | 777 | protocol, bag, normal, fluid, potassium, saline, infusion, commence, insulin |
tramadol | 1230 | 703 | cupboard, release, CD [controlled drugs] book, capsule, book, tablet, stock, immediate |
midazolam | 1207 | 727 | draw, vial, fentanyl, unresponsive, morphine, syringe, book, care, end |
enaxoparin | 1201 | 826 | treatment dose, prophylactic, sc, critical, INR, sign, prophylaxis, injection |
anaesthetic | 1114 | 819 | record, immediately, post, case, surgery, theatre, list, surgeon |
Tazocin [piperacillin / tezobactam] | 1078 | 774 | penicillin, intravenous, rash, reaction, allergy, antibiotic, sepsis, allergic |
chloride | 1068 | 747 | flush, bag, fluid, potassium, saline, infusion, water, dilute, label |
tinzaparin | 1049 | 643 | INR, therapeutic tinzaparin, treatment dose, therapeutic, warfarin, unit, injection |
aspirin | 879 | 582 | chest pain, omeprazole, fondaparinex, Ramipril, ticagrelor, stroke, lansoprazole, clopidogrel |
Clusters
Cluster | Descriptive termsb | No. | % | RMSSDa |
---|---|---|---|---|
1 | syringe, driver, infusion, label, pump, run, morphine, line, commence, running | 1516 | 2 | 0.093 |
2 | infusion, hour, rate, pump, check, run, intravenous, start, running, stop | 3317 | 5 | 0.102 |
3 | allergy, penicillin, allergic, amoxicillin, reaction, intravenous, note, state, document, antibiotic | 1258 | 2 | 0.077 |
4 | patch, fentanyl, find, buprenorphine, ‘fentanyl patch’, apply, remove, date, pain, visit | 1002 | 1 | 0.069 |
5 | insulin, administer, morning, blood, unit, scale, diabetic, glucose, sugar, visit | 3595 | 5 | 0.100 |
6 | nurse, ward, staff, pharmacy, inform, night, doctor, discharge, pharmacist, home | 15,709 | 22 | 0.126 |
7 | find, date, bottle, box, chemotherapy, treatment, cupboard, pain, attend, book | 8795 | 12 | 0.134 |
8 | warfarin, dose, INR, chart, dalteparin, prescribe, day, doctor, sign, visit | 962 | 1 | 0.075 |
9 | paracetamol, patient, dose, intravenous, discharge, hour, home, pain, oral, medication | 3455 | 5 | 0.113 |
10 | drop, eye, eye drop, right left, chloramphenicol, bottle, pharmacy, attend, treatment | 692 | 1 | 0.073 |
11 | medication, patient, ward, administer, morning, sign, miss, wrong, pharmacy, transfer | 5041 | 7 | 0.108 |
12 | morphine, check, sulphate, pca, pain, prescription, control, book, oral, syringe | 1816 | 3 | 0.098 |
13 | patient, tablet, drug, check, oxycodone, find, book, release, control, cupboard | 3969 | 5 | 0.114 |
14 | injection, administer, scan, unit, contrast, dalteparin, cannula, extravasation, arm, attend | 2632 | 4 | 0.115 |
15 | dose, patient, prescribe, miss, administer, day, morning, night, sign, due | 6964 | 10 | 0.115 |
16 | intravenous, antibiotic, prescribe, fluid, intravenous antibiotic, oral, intravenous infusion, hour, saline | 4884 | 7 | 0.115 |
17 | bag, tpn, find, fluid, pharmacy, run, saline, line, start, running | 2530 | 3 | 0.110 |
18 | drug chart, drug, dose, prescribe, sign, day, note, morning, notice | 4253 | 6 | 0.099 |
Total | 72,390 | 100 |
Risk areas of medication administration
“Received patient from ED [emergency department]. Viewed drug chart with transfer nurse and found patient was given amoxicillin despite having an allergic reaction to penicillin. Patient was closely monitored for signs of anaphylaxis and doctors were aware...”
“Three doses intravenous antibiotics missed due to no venous access. Last dose IV [intravenous] Antibiotics given 24 hours earlier on 17 / 3 / 16 at 22:00. Patient states no one had tried to site a cannula since 10:00am. Patient is post-operative chronic congenital neutropaenic in Cubicle…”
“On changing patient Fentanyl patch as per Drug Chart, I noted that there were two other fentanyl patches in situ x1 on Left arm, x1 on Right chest…”
“Came on shift (12/10) went to give morphine for a patient. Was looking through the CD [controlled drugs] book to double check when he last was given it. noted that they had but 10mg -5mls out of the CD book. when he was only prescribed 5mg-2.5mls...”
“Doctor re-prescribed warfarin dose after checking INR [international normalized ratio] level, stated patient was now on 4mg dose, 4mg warfarin given, went to sign drug card and realised pt [patient] had 3mg at 18:00, patient has now had 7mg warfarin…”
“Morning dose of fast acting and long acting insulin missed. Patient has not received his breakfast yet at the time when morning medication was done. Informed patient that I will return to do his insulin when he gets his breakfast, however failed to return due to ward distractions. Mistake was noted at 12:00 when blood sugars was done before lunch and noted to be 23.”
“Patient has been administered the wrong medication. On the drug chart was prescribed normal saline 0.9 % with Potassium 40 mmol and patient was having Potassium Chloride 0.3% + Sodium Chloride 0.18% and Glucose 4 %. The prescription was signed and checked by day team who was looking after the patient…”