Table 1

Summary of study participants and reported intravenous MAEs

Participant codeGenderYears since qualification*Environment at time of MAEType of MAEDid the error reach the patientMedication classActive failure(s)
N01F0–4WardWrong rateYesRespiratorySlip
N02F5–9WardWrong doseYesCardiovascularKBM
N03M0–4WardWrong drug†‡YesAntimicrobialViolation
N04F0–4WardWrong doseYesEndocrineSlip
N05F10+WardWrong rateYesElectrolyteSlip
N06F0–4WardWrong rateYesCardiovascularKBM
N07F5–9WardWrong rateYesAntimicrobialKBM
0–4WardWrong administration techniqueYesCardiovascularLapse
N08F0–4WardWrong drug‡YesAntimicrobialLapse
N09F0–4WardWrong rateYesRespiratorySlip
N10F0–4WardWrong dose†NoCardiovascularKBM
N11M5–9WardWrong drug†‡YesAntimicrobialViolation
N12F0–4TheatreWrong preparation§¶YesCNSViolation (×2)
N13M10+WardWrong preparationYesAntimicrobialKBM
N14F10+WardUnordered drug‡§YesEndocrineSlip
N15F10+WardExtra dose†‡§YesCNSRBM
N16F0–4WardWrong rateYesAntimicrobialSlip
N17F10+WardWrong preparation¶YesCardiovascularLapse
N18F5–9WardWrong rateYesCardiovascularRBM
N19F10+TheatreWrong preparation§¶YesCNSSlip, RBM
N20F10+TheatreWrong doseYesCardiovascularLapse
  • *Number of years after qualified/licensed as a nurse that intravenous MAE occurred.

  • †Indicates occasions where nurses prepared and/or administered prescribing errors (eg, poorly written prescription).

  • ‡Wrong drug, wrong patient, unordered drug and extra dose errors are considered ‘unauthorised drug errors’.

  • §Indicates occasions where a complex chain of events involving different professional groups was involved.

  • ¶Indicates wrong label errors within wrong preparation group.

  • CNS, central nervous system; F, female; KBM, knowledge-based mistake; M, male; MAE, medication administration error; RBM, rule-based mistake.