Table 1

Frequency of incidents within each category and subcategory

Subcategory of incidentsNumber of incidentsPercentage (%) of total number of Incidents
Administration—drug incompatibility30.8
Administration—incorrect day or time143.6
Administration—incorrect dose328.3
Administration—incorrect drug164.1
Administration—incorrect frequency205.2
Administration—incorrect rate102.6
Administration—incorrect route112.8
Administration—non-administration/dose omitted or significantly delayed6717.3
Administration—self-administration error61.6
Administration—extravasation369.3
Subtotal administration incidents21555.6
 Discharge—delay in pharmacy processing of TTO41.0
 Discharge—delay in prescribing of TTO20.5
 Discharge—patient discharged with incomplete set of medication or no medication82.1
Subtotal discharge incidents143.6
 Other—clinical trial error (prescribing, dispensing, administration, protocol violation)41.0
 Other—contraindication to the use of the medicine164.1
 Other—discrepancy in medication documentation records (CDs, drug chart and so on)41.0
 Other—drug wastage (financial loss)61.6
 Other—faulty medicinal product20.5
 Other—incorrect injectable drug preparation: prescribing, administration, manufacturing (incorrect concentration/diluent, incorrect volume, incorrect drug/dose, incorrect label/ details missing on label)41.0
 Other—incorrect monitoring/failure to monitor therapeutic levels71.8
 Other—mismatching between patient and medicine (misidentification)20.5
 Other—missing medication or drug chart51.3
 Other—new adverse drug reaction/unexpected response/oversensitivity to drug4411.4
 Other—patient with known allergy prescribed or administered a drug they are allergic to41
 Other—storage or transportation issues20.5
 Other—wrong expiry/omitted expiry/passed expiry date20.5
Subtotal other incidents10226.4
 Pharmacy—clinical pharmacist screening error22.6
 Pharmacy—incorrect directions on label10.3
 Pharmacy—incorrect information or pharmacy advice (endorsement on chart, verbal or written information)10.3
 Pharmacy—significant delay in supply or failure to supply (not TTOs)10.3
 Pharmacy—transcription error10.3
 Pharmacy—Unavailable medication stock41.0
Subtotal pharmacy incidents102.6
 Prescribing—failure to prescribe a planned prescription102.6
 Prescribing—incorrect day or time30.8
 Prescribing—incorrect dose194.9
 Prescribing—incorrect drug102.6
 Prescribing—incorrect frequency30.8
 Prescribing—incorrect rate10.3
Subtotal prescribing incidents4611.9
Grand total387100