Table 4 The most serious medication errors involving high-alert medications (n = 18) within the sub-sample (n = 16/743 medication error reports)

Morphine (n = 6, 33.3%)

• Infusion rate programmed 12.5 mL/h instead of 2.5 mL/h

• A full daily dose prescribed six times, although the daily dose should have been divided into six doses

• PO dose accidentally given IV

• Three IV doses given within 30 min prior to the transfer resulted in the deterioration of the patient’s condition in the receiving unit

• The patient received accidentally another patient's medicine

• Morphine IV infusion prescribed and given at 3.5 mL/h instead of 0.35 mL/h

Aspartinsulin (n = 2, 11.1%)

• CVC blood glucose samples were contaminated by glucose infusion, which led to unnecessary dose increases of IV infusion and hypoglycemia

• The changes made into the insulin pump were not approved, which resulted in a new order on incorrect grounds the next day

Enoxaparin (n = 2, 11.1%)

• A fivefold dose, because the dose was prepared from the undiluted medicine (100 mg/ml) instead of the diluted one (20 mg/ml)

• The dose was decreased to from 20 to 10 mg (no prefilled syringe available), but a 100 mg syringe was mistakenly prescribed

Oxycodone (n = 2, 11.1%)

• PO dose prescribed to IV route

• A respiratory arrest resulting from a combination of too many PCA boluses and epidural analgesia

Carboplatin (n = 1, 5.6%)

• Too rapid etoposide infusion (1 h instead of 3 h) because of a mix-up between infusion times

Etoposide (n = 1, 5.6%)

Dopamine (n = 1, 5.6%)

• 100-fold infusion rate because of pump programming error (23 mL/h instead of 0.23 mL/h)

Heparin flush (n = 1, 5.6%)

• Accidental administration of parenteral nutrition to IA line after a mix-up between infusion syringes

Parenteral nutrition (n = 1, 5.6%)

Vincristine (n = 1, 5.6%)

• An extra dose given to a patient suffering from neuropathy, because the previous dose was recorded in the wrong place