Procedural failures (eg, checking patient identification) and clinical intravenous errors (eg, wrong intravenous administration rate) were identified and categorised by severity.
Possible consequences of the workarounds include wrong administration of medications, wrong doses, wrong times, and wrong formulations.
The sole cause of the accident described in this case is certainly the wrong administration of Ultiva™ solution into the epidural space.
Wrong dose errors, wrong dosage-form errors, wrong drug-preparation errors, and wrong administration technique errors were rare (n = 8 for each type, 1.9%).
Three out of four permanent harms were due to wrong administration of drugs.
Event date, birth date of patient, gender, practice, event category (prescribing error (wrong prescription, wrong administration; wrong dose; other), adverse reaction (adverse reaction; allergic reaction; overdose; interaction; contra-indication; other), dispensing error (too late; wrong medicine; wrong dose; other)), and additional remarks or context were recorded.
Wrong administration technique including injectable drugs could be decrease with nurse training and awareness to manipulate injectable drugs.
The reliability of the algorithm is tested by the wrong segmentation rate.
8. Infusion rate of continuous medication (wrong rate, rate omitted).
In contrast, medication administration tasks such as administering medication via infusion pumps or intravenous push were found to be susceptible to errors of commission (eg, setting the wrong infusion rate).
