During my shift, one of the following medication-error-related events occurred (please mark with a cross) |
Medication administration | □ | 1. I administered a wrong medication to a patient |
| 2. I administered a medication at the wrong time: □ More than 30 min earlier or later than ordered □ More than 60 min earlier or later than ordered More than 120 min earlier or later than ordered
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□ | 3. I administered a medication in a wrong dosage |
□ | 4. I administered a medication to the wrong patient |
□ | 5. I administered a medication in the wrong route |
□ | 6. I forgot to administer a medication |
Physician ordering with CPOE | □ | 7. A wrong medication was prescribed |
□ | 8. A medication prescription was ordered at the wrong time |
□ | 9. A medication prescription was ordered in a wrong dosage |
□ | 10. A medication prescription was ordered to the wrong patient |
□ | 11. A medication prescription was ordered the wrong route |
□ | 12. A medication was forgotten to prescribe |
Medication dispensing | □ | 13. At the medication control a prescribed medication was not dispensed |
| 14. At the medication control I have found the following error: □ A wrong medication was dispensed □ A medication was dispensed at the wrong time □ A medication was dispensed in a wrong dosage □ A medication was dispensed to the wrong patient □ A medication was dispensed in wrong route
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Anaesthesia ordering | | 15. Have you controlled a prescription by anaesthesia during your shift pre-or postoperatively? □ Yes (if yes, please go to question 10, 11, 12 and 13) □ No (please continue with question 14)
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□ | 16. A medication prescription by anaesthesia was illegible |
□ | 17. A medication prescription by anaesthesia was incomplete |
□ | 18. A medication prescription by anaesthesia was wrong |
□ | 19. A medication prescription by anaesthesia was transcribed wrong |
Patient consequences | □ | 20. The medication error event had no consequences for the patient |
□ | 21. The medication error event had consequences for the patient. If yes, what are the consequences? (use the space below) |
Workload | | 22. Please evaluate your workload of the present shift: |
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| 23. If the workload was high or very high, please write down the reason: |
Shift | □ | 24. No medication error-related event happened to me during my shift |
| 25. Please mark your shift: |
| Morning shift □ | Evening shift □ | Night shift □ |