• Ingvill Marie Teigen, Kristin Lein Rendum, Lars Slørdal, and Olav Spigset.
• Avdeling for klinisk farmakologi, St. Olavs hospital, 7006 Trondheim.
• Tidsskr. Nor. Laegeforen. 2009 Jun 25; 129 (13): 1337-41.

BackgroundMedication errors can arise both during prescription and administration (dispensing and distribution) of drugs. Little is known about types of medication errors in Norwegian hospitals.Material And MethodAll medication errors reported at St. Olav's Hospital from 1 July 2002 to 30 June 2006 were reviewed and analysed.Results610 reports were identified. The most common cause of reporting (39 %) was prescription of a different dose from the one prescribed. Other frequent causes were administration of a different drug than the one prescribed (17 %), inadvertent subcutaneous infusion of an intravenous drug (15 %), and that the drug was given to another patient (12 %). The errors were almost exclusively reported by nurses. In 107 cases (18 %), precautions had been taken to reduce the extent of injury after the error had been identified. The causes of errors could be classified in three main categories: Nonvigilance caused by stress, lack of appropriate routines or violation of them, and lack of appropriate skills/negligence.InterpretationChanges of routines, improved education in existing routines, and increased pharmacological competence may contribute to prevention of medication errors.

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