Number, frequency and relationship of discrepancies to resultant errors with subanalysis of major discrepancies that resulted in large magnitude and clinically significant errors
| Stage of deviation | Total discrepancies (n) | Relationship to resultant errors | ||||
| No contribution n (%*) | Minor contribution n (%*) | Discrepancies which made a major contribution to a medication error | ||||
| Major contribution, total (n, %*) | Discrepancies that resulted in clinically significant errors (n, %*) † | Discrepancies that resulted in large magnitude errors n (%*) ‡ | ||||
| Overall | 884 | 710 (80) | 104 (12) | 70 (8) | 33 (47) | 31 (44) |
| Ordering phase | 170 | 159 (94) | 2 (1) | 9 (5) | 5 (23) | 6 (22) |
| Determine dose | 29 | 21 (72) | 1 (3) | 7 (24) | 5 (23) | 6 (22) |
| Dose from memory | 4 | 2 (50) | – | 2 (50) | – | 1 (4) |
| Dose from formulary | 10 | 6 (60) | 1 (10) | 3 (30) | 3 (14) | 3 (11) |
| Dose from other resource | 11 | 10 (91) | – | 1 (9) | 1 (5) | 1 (4) |
| Dose calculation | 4 | 3 (75) | – | 1 (25) | 1 (5) | 1 (4) |
| Issue order | 141 | 138 (98) | 1 (1) | 2 (1) | – | – |
| Issue verbal order | 136 | 134 (98) | 1 (1) | 1 (1) | – | – |
| Issue written order | 5 | 4 (80) | – | 1 (20) | – | – |
| Preparation phase | 588 | 456 (78) | 89 (15) | 43 (7) | 17 (77) | 13 (48) |
| Check order | 19 | 6 (32) | 9 (47) | 4 (21) | 3 (14) | 1 (4) |
| Check drug name | 1 | – | – | 1 (100) | 1 (5) | 1 (4) |
| Check dose for indication | 15 | 5 (33) | 8 (53) | 2 (13) | 1 (5) | – |
| Check calculation | 1 | – | 1 (100) | – | – | – |
| Check route and timing | 2 | 1 (50) | – | 1 (50) | 1 (5) | – |
| Preparation, actual | 310 | 263 (85) | 8 (3) | 39 (13) | 14 (64) | 12 (44) |
| Find correct medication and strength of vial | 2 | – | 2 (100) | – | – | – |
| Check intravenous administration guidance | 42 | 22 (52) | 1 (2) | 19 (45) | 9 (41) | 6 (22) |
| Check ampoule | 1 | – | 1 (100) | – | – | – |
| Check reconstitution fluid and volume | 7 | 3 (43) | 1 (14) | 3 (43) | – | – |
| Convert milligrams to millilitres | 7 | 2 (29) | – | 5 (71) | 3 (14) | 4 (15) |
| Find correct syringe and draw neat volume | 8 | 3 (38) | – | 5 (63) | 1 (5) | 1 (4) |
| Determine correct concentration for route | 2 | 2 (100) | – | – | – | – |
| Calculate further diluent volume and dilute | 12 | 4 (33) | 1 (8) | 7 (58) | 1 (5) | 1 (4) |
| Label syringe with drug name, dose and concentration if appropriate | 231 | 227 (98) | 4 (2) | – | – | – |
| Double checking | 259 | 187 (72) | 72 (27) | – | – | – |
| Check reconstitution | 9 | 5 (57) | 4 (44) | – | – | – |
| Check dose and neat volume | 69 | 48 (70) | 21 (30) | – | – | – |
| Check diluent volume and total volume separately | 86 | 63 (73) | 23 (27) | – | – | – |
| Check ampoule+expiry | 29 | 26 (90) | 3 (10) | – | – | – |
| Check rate/method | 66 | 45 (68) | 21 (32) | – | – | – |
| Administration phase | 28 | 8 (29) | 2 (7) | 18 (64) | 11 (50) | 12 (44) |
| Boluses: inject | 2 | 1 (50) | 1 (50) | – | – | – |
| Infusions: determine run rate | 8 | – | 1 (13) | 7 (88) | 5 (23) | 5 (19) |
| Determine Y-site compatibility | 2 | 2 (100) | – | – | – | – |
| Determine delivery rate for continuous infusions | 7 | 3 (43) | – | 4 (57) | 3 (14) | 4 (15) |
| Programme infusion pump | 9 | 2 (22) | – | 7 (78) | 3 (14) | 3 (11) |
| Recording | 88 | 88 (100) | – | – | – | – |
*The denominator for percentages is the total number of discrepancies in each row.
†Number and percentage of clinically significant errors (severity score >3) with major contributory discrepancies made at each specific step, of a total of 22 clinically significant errors.
‡Number and percentage of large magnitude errors (deviation from recommended dosing range (DRDR) or deviation from recommended dosing rate (DRDRate) >25%) with major contributory discrepancies made at each specific step, of a total of 27 large magnitude errors.