Patient accidentally took 1 Yes Once daily dose taken When available, it is tablet twice daily instead of more frequently important to select a the prescribed 1 tablet specific LLT for the once daily reported scenario, rather than just the LLT that matches the PT Inappropriate schedule of drug administration, allowing further on the LLT level. Although the LLT does not capture that it was accidental, it falls under HLT Product administration errors and issues. Tablet crumbled while it Yes, Tablet physical crumbled” in this “Tablet was taken out of the blister consequent scenario is a product pack, but was still to a product quality issue (LLT Tablet Poor quality drug administered to the patient quality issue physical issue); do not administered select a medication error term such as LLT Tablet The crushed incorrectly. error is that a product with a known quality issue (“crumbled”) was still administered to the patient. Syringe plunger couldn’t Yes, Syringe issue Capture both the device be completely pushed consequent issue and the down so the patient to a delivery consequent medication Incorrect dose received only half of his device issue error administered by scheduled dose device A patient reported that he Yes, Device delivery followed the directions for consequent system malfunction use, but the pen jammed to a delivery and most of the injection device issue Accidental exposure sprayed all over his hands while administering drug Exposure via skin contact
Patient accidentally took 1 tablet twice daily instead of the prescribed 1 tablet once daily Yes Once daily dose taken more frequently When available, it is important to select a specific LLT for the reported scenario, rather than just the LLT that matches the PT Inappropriate schedule of drug administration, allowing further on the LLT level. Although the LLT does not capture that it was accidental, it falls under HLT Product administration errors and issues. Tablet crumbled while it was taken out of the blister pack, but was still administered to the patient Yes, consequent to a product quality issue Tablet physical Poor quality drug administered “Tablet crumbled” in this scenario is a product quality issue (LLT Tablet physical issue); do not select a medication error term such as LLT Tablet crushed incorrectly. The error is that a product with a known quality issue (“crumbled”) was still administered to the patient. Syringe plunger couldn’t be completely pushed down so the patient received only half of his scheduled dose Yes, consequent to a delivery device issue Syringe issue Incorrect dose administered by device Capture both the device issue and the consequent medication error A patient reported that he followed the directions for use, but the pen jammed and most of the injection sprayed all over his hands Yes, consequent to a delivery device issue Device delivery system malfunction Accidental exposure while administering drug Exposure via skin contact