Medication Erros

Question 1

“Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer. Such events may be. Such events may be related to professional practice, health care products, procedures, and systems, including prescribing, order communication, product labelling, packaging, and nomenclature, compounding, dispensing, distribution, administration, education, monitoring, and use”.

Answer 1

Medication Error

Question 2

through lack of knowledge

Answer 2

knowledge-based errors

Question 3

using a bad rule or misapplying a good rule

Answer 3

rule-based errors

Question 4

called slips

Answer 4

action-based errors

Question 5

called lapses

Answer 5

memory-based errors

Question 6

no error; capacity to cause error

Answer 6

A

Question 7

error, but did not reach the patient

Answer 7

B

Question 8

error that reached the patient but unlikely to cause harm (omissions considered to reach the patient)

Answer 8

C

Question 9

error that reached the patient and could have necessitated monitoring and/or intervention preclude harm

Answer 9

D

Question 10

error that could have caused temporary harm

Answer 10

E

Question 10

error that could have caused temporary harm requiring initial or prolonged hospitilization

Answer 10

F

Question 11

error that could have resulted in permanent harm

Answer 11

G

Question 12

error that could have necessitated intervention to sustain life

Answer 12

H

Question 13

error that could have resulted in death

Answer 13

I

Question 14

no example given

Answer 14

A and B

Question 15

multivitamin was not ordered for admission

Answer 15

C

Question 16

regular release metoprolol was ordered for patient instead of extended-release

Answer 16

D

Question 17

blood pressure medication was inadvertently omitted from the orders

Answer 17

E

Question 18

anticoagulant such as warfarin was ordered daily when the patient takes it every other day

Answer 18

F

Question 19

immunosuppressant medication was unintentionally ordered at one-fourth the dose

Answer 19

G

Question 20

anticonvulsant therapy was inadvertently omitted

Answer 20

H

Question 21

beta-blocker was not reordered post-operatively

Answer 21

I

Question 22

salbutamol inhaler was unintentionally removed from the list of orders

Answer 22

H

Question 23

e-zinc drops was given instead of Cetirizine drops.

Answer 23

C

Question 24

alteplase was given instead of tranexamic acid.

Answer 24

D

Question 25

mefenamic acid was not prescribed after a tooth extraction.

Answer 25

E

Question 26

a. wrong dose
b. wrong route
c. wrong patient
d. wrong time
e. wrong frequency
f. wrong drug
g. illegible or ambiguous prescription
h. prescribe a drug to a patient with an allergy
i. drug interaction

Answer 26

prescribing error

Question 27

a. omit key information
b. re-writing doses

Answer 27

transcribing error

Question 28

a. incorrect preparation of drug or infusion solution
b. dispense an expired drug
c. incorrect written information on drug label
d. equipment failures.
e labelling errors
f. wrong drug.
g. poor drug storage practice
h. drug dispensed too late
i. dspense non-standard drug concentration

Answer 28

dispensing error

Question 29

a. wrong route
b. wrong dose
c. wrong time
d. incorrect frequency
e. wrong patient
f. drug not administered
g. double checking omissions
h. prepare incorrect infusant solution
i. non-compliance failure

Answer 29

administration error

Question 30

The patient’s chemotherapy dosage is calculated based on an old weight so the dose is too low.

Answer 30

prescribing error

Question 31

Dose, drug, route, frequency or patient information is omitted when the prescription is transcribed.

Answer 31

transcribing error

Question 32

Poor quality sticky labels fall off syringes during transfer from pharmacy to the ward.

Answer 32

dispensing error

Question 33

Vincristine or vinblastine administered intrathecally rather than intravenously

Answer 33

administration error

Question 34

Intravenous vincristine is prescribed for intrathecal administration.

Answer 34

prescribing error

Question 35

Ceftriaxone dispensed instead of clindamycin.

Answer 35

dispensing error

Question 36

Pediatric patient who was recovering from brain tumour surgery is given a 650-mg dose

Answer 36

administration error

Question 37

A drug is prescribed for patient A which is meant for patient B.

Answer 37

prescribing error

Question 38

Four patients on a busy surgical ward receive their intravenous antibiotics 45±60 min late

Answer 38

administration error

Question 39

Poor handwriting of the prescriber

Answer 39

prescribing error

Question 40

A doctor prescribe a drug to which a patient has a known allergy

Answer 40

prescribing error

Question 41

300 mg of morphine, prescribed to a terminally ill cancer patient, is given in error to the patient in an adjoining room of a nursing home

Answer 41

administration error

Question 42

The doctor mistakenly writes a prescription for cyclophosphamide so that the combined 4-d dose is to be given in 1 d, instead of once daily over 4 d.

Answer 42

prescribing error

Question 43

Mis-prescribed 10-fold digoxin dose for 3á2 kg newborn baby was given by a nurse even though hospital policy stated that only medical staff could administer this drug

Answer 43

administration error