Background
Methods
Meaning unit | Condensation | Main category | Sub-category | |
---|---|---|---|---|
Nurse finds an opened vial with sodium chloride solution on the tray “as it usually is” and injects 5 ml. Later, two unopened vials of sodium chloride solution and one opened vial of potassium chloride solution are found on the tray. | Nurse found an opened vial of sodium chloride. “As it usually is.” “No thought that it could be anything else” | Potassium chloride instead of sodium chloride | Medication error type | Wrong drug due to mix-up of drugs |
“I read on the vial, but I didn’t notice what it said.” “She didn’t notice of the small dose prescribed, but took it for granted that the patient should have an ordinary dose.” “I totally forgot about the medication.” | Did not pay attention to the content of the text Didn’t notice and took for granted Forgot to give the medicine to the patient | Insufficient attention Took for granted Forgot | Individual factor | Negligence, forgetfulness or lack of attentiveness |
“I was alone and the medication administration must be done at all the wards at the same time” | Alone with all administration at the same time | To much work to perform in insufficient time | System factor | Role overload |
Error type | N (%) | Stories illustrating the categories |
---|---|---|
Wrong dose | 241 (41) |
Due to bad communication between a nurse and an assistant nurse, they both gave a woman with diabetes insulin.
|
Wrong drug | 96 (16) |
A man with heart failure was given morphine instead of furosemide intravenously because the nurse was thinking of another patient.
|
Wrong patient | 76 (13) |
An in-patient was given drugs that were meant for the patient in the next bed.
|
Omission | 69 (12) |
A patient did not get warfarin for 2 weeks since the medication was temporarily discontinued and then forgotten.
|
Unauthorized drug | 57 (10) |
A nurse gave a patient with severe pain a higher dose of analgesics than prescribed because the lower dose had not resulted in pain relief. No physician was available at the time.
|
Wrong route | 35 (6) |
Due to a misunderstanding of the nurse’s instructions, an assistant nurse administered ear drops into the eyes of a nursing home patient.
|
Wrong judgement (or inadequate assessment of the patient’s need for treatment) | 16 (3) |
A patient who had very a low blood sugar was nevertheless given her prescribed dose of insulin.
|
Wrong management or storage of the drug, | 11 (2) |
A nurse who could not find the proper drug picked up a package from a box of discarded drugs and gave it to the patient.
|
Allergy-related error | 9 (2) |
Using the department’s the list of drugs that nurses are allowed to administer occasionally without a doctor’s order, a nurse administered alimemazine to a patient from without noticing that the patient was allergic to this drug.
|
Other | 3 (<1) | |
Total numbers of errors in the 585 cases | 613 |
Individual contributory factors | N (%) | Stories illustrating the categories. |
---|---|---|
Negligence, forgetfulness or lack of attentiveness | 399 (68) |
One nurse put two vials on the table in a cancer patient’s home. The prescription was Hydromorphone 10 mg/ml, 1.8 ml s.c. and Morphine 10 mg/ml, 9 ml i.v. Hydromorphone is five times stronger than Morphine.
Another nurse gave an intravenous injection from a 10 ml. vial. When she was about to give Hydromorphone, that she believed existed only in 1 ml vials, she could not find it on the table. She now realized that she has given Hydromorphone instead of Morphine.
A temporarily employed doctor had prescribed ordered both Morphine and Hydromorphone in 10 ml vials.
|
Proper protocol not followed | 147 (25) |
A man with acute stroke had recently been treated for a myocardial infarction and was therefore admitted to the cardiology department for treatment of his stroke. He was prescribed ateplase as thrombolytic therapy. The nurse was familiar with this drug in cardiology practice but not for stroke.
Alteplase consists of two vials to be mixed by the nurse, but the dosage and the preparation are different for different diagnoses. With one of the vials in her hand, the nurse walked around and asked several doctors and nurses about the procedure. Then she mixed the ateplase infusion and administered it to the patient.
The next morning, the vial with the active ingredient was found at the table in the doctor’s office.
|
Lack of knowledge | 76 (13) |
The same case as Proper protocol not followed.
|
Practice beyond scope of practice | 68 (12) |
A nursing home patient with severe cancer pain was prescribed dextropropoxyphene and paracetamol 4 times a day and morphine 5 mg “when needed”.
On a Saturday, pain had worsened in spite of morphine 4 doses daily. The RN changes the order to paracetamol and morphine 5 mg four times daily and excluded dextropropoxphene.
The physician thought that the RN had passed her authorization when not consulting a physician.
|
Inappropriate communication | 62 (11) | A nursing home patient was prescribed tramadol 1–2 tablets “when needed”. The RN put 8 tablets in a medicine cup labelled “tramadol when needed”.
An assistant nurse with an authorization to administer drugs gave the patient all 8 tablets at the same time.
The RN had failed in her communication to the assistant nurse giving incomplete information.
|
Disease or drug abuse | 203 (3) |
The nurse had used the patient’s morphine herself.
The patient did not get any morphine.
|
No individual factor identified | 29 (5) | |
Total numbers of individual factors in the 585 cases | 772 |
System factors | N (%) | Stories illustrating the categories |
---|---|---|
Role overload | 212 (36) |
A child with a heart failure in an intensive care unit was to be transported to another hospital. The nurse could not find sodium chloride solution to flush the peripheral intravenous catheter and went into another patient room where he found a tray of opened sodium chloride solution vials.
He flushed the catheter and the child immediately turned blue and stopped breathing.
Two unopened vials of sodium chloride and one opened vial of potassium chloride were found on the tray.
The nurse had felt stressed. The child had been in a serious condition during the night, and was not fed: The papers were not ready and the transport car did not have access to oxygen.
|
Inappropriate location of medication or look-alike medication | 79 (14) | |
Unclear communication or orders | 177 (30) |
An 80-year old lady was transferred from the intensive care unit to a general ward.
A nurse copied the patient’s drug orders from the intensive care list to the medical care list by hand.
She wrote “Digoxin 0.25 mg. 1 + 1 + 1” instead of “Digoxin 1 + 0 + 0”. The physician signed the order without noticing the error.
The patient got the higher dose during 12 days.
|
Lack of adequate access to guidelines or unclear organisational routines “The case also illustrates “Proper protocol not followed” in Table III | 176 (30) |
A man with acute stroke had recently been treated for a myocardial infarction and was therefore admitted to the cardiology department for treatment of his stroke. He was prescribed alteplase as thrombolytic therapy. The nurse was familiar with this drug in cardiology practice but not for stroke.
Alteplase consists of two vials to be mixed by the nurse, but the dosage and the preparation are different for different diagnoses. With one of the vials in her hand, the nurse walked around and asked several doctors and nurses about the procedure. Then she mixed the ateplase infusion and administered it to the patient.
The next morning, the vial with the active ingredient was found at the table in the doctor’s office.
|
Interruption or distraction when preparing or administering medication | 47 (8) |
A nurse was preparing an infusion of furosemide and sodium chloride and in the room for storage and preparation of medications.
The door was open and another patient in pain asked for morphine and begged the nurse to hurry up. The nurse replied that she would first finish what she started and then come with the morphine. The patient was standing in the door and talked to the nurse when she prepared the infusion.
She mixed morphine instead of furosemide in the infusion and gave to a patient with heart failure.
The nurse wrote that when she prepared the infusion, she was thinking of the patient needing morphine.
|
Inadequate technique or pharmaceutical service | 31 (5) |
A patient would receive chemotherapy and the pharmacy delivered the wrong drug. The name of the mis-delivered vial was long and therefore an abbreviation was used. The difference in name between the various drugs did not appear in the abbreviation.
The nurse read the abbreviation on the vial and compared with the prescription.
The nurse took for granted that it was the right drug delivered and gave it to the patient.
|
Pressure from patient/patient’s family or other staff members to satisfy the patient’s immediate need | 28 (5) |
A father came with his 7 year old son to the health centre. He claimed that it was the day for his son to get his monthly injection of growth hormone.
The RN had worked in the centre for 2 weeks and could not find any notes about the injection in the child’s medical record. She questioned if it was the right day and what dose to give. The father was stubborn and claimed that he knew the dose and that his son must have his injection.
The father seemed trustworthy and the RN gave the boy the injection.
The boy got a too high dose and one week too early.
|
Administration in an emergency situation | 7 (1) |
The patient got a double dose of furosemide due to a communication misunderstanding in an acute situation.
|
None | 130 (22) | |
Total numbers of system factors in the 585 cases | 757 |
Statistics
Results
The medication errors (MEs)
The individual contributory factors (ICFs)
The system contributory factors (SCFs)
Experienced versus un-experienced nurses
Nurse’s work experience | ||||
---|---|---|---|---|
0–2 years | >2 years |
p
| ||
n = 55 | N = 317 | |||
Error type | ||||
1 | Wrong dose | 20 (36.4 %) | 140 (44.2 %) | 0.305 |
2 | Wrong drug due to mix-up of drugs | 9 (16.4 %) | 51 (16.1 %) | 1.000 |
3
|
Wrong patient due to mix-up of patients
|
14 (25.5 %)
| 34 (10.7 %) |
0.007
|
4 | Omission | 3 (5.5 %) | 35 (11.0 %) | 0.332 |
5 | Unauthorized drug | 2 (3.6 %) | 35 (11.0 %) | 0.139 |
6
|
Wrong route
|
9 (16.4 %)
| 14 (4.4 %) |
0.003
|
7 | Wrong judgement or inadequate assessment of the patient’s need for treatment | 1 (1.8 %) | 9 (2.8 %) | 1.000 |
8 | Wrong management or storage of the drug | 1 (1.8 %) | 7 (2.2 %) | 1.000 |
9 | Allergy-related error | 0 (0.0 %) | 5 (1.6 %) | 1.000 |
Individual contributory factor | ||||
1
|
Negligence, forgetfulness or lack of attentiveness
|
46 (83.6 %)
| 207 (65.3 %) |
0.007
|
2 | Proper protocol not followed | 13 (23.6 %) | 82 (25.9 %) | 0.867 |
3
|
Lack of knowledge
|
17 (30.9 %)
| 37 (11.7 %) |
0.001
|
4
|
Practice beyond scope of practice
| 1 (1.8 %) |
48 (15.1 %)
|
0.004
|
5 | Inappropiate communication | 3 (5.5 %) | 33 (10.4 %) | 0.328 |
6 | Disease or drug abuse | 1 (1.8 %) | 13 (4.1 %) | 0.703 |
System contributory factor | ||||
1 | Role overload | 25 (45.5 %) | 117 (36.9 %) | 0.233 |
2 | Unclear communication or orders | 13 (23.6 %) | 87 (27.4 %) | 0.624 |
3
|
Lack of adequate access to guidelines or unclear organisational routines
| 9 (16.4 %) |
97 (30.6 %)
|
0.035
|
4 | Inappropriate location of medication or look-alike medication | 7 (12.7 %) | 40 (12.6 %) | 1.000 |
5 | Interruption or distraction when preparing or administering medication | 8 (14.5 %) | 22 (6.9 %) | 0.064 |
6 | Inadequate technique or pharmaceutical service | 2 (3.6 %) | 23 (7.3 %) | 0.557 |
7 | Pressure from patient/family or other staff members to satisfy the patient’s immediate needs | 2 (3.6 %) | 21 (6.6 %) | 0.551 |
8 | Administration in an emergency situation | 1 (1.8 %) | 6 (1.9 %) | 1.000 |