Spreadsheet: 106128eb-1c65-41a0-9ca6-d4b91a4b2fed
Sheet: Sheet1

ACTIVE PHARMACEUTICAL SUBSTANCE | SECTOR | ATC CODE | ERROR TYPE | MEDICATION PROCESS STAGE | ERROR DESCRIPTION | [NAME] | FACTUAL CONSEQUENCE | DOCUMENTATION | SOURCE
Insulin |  | A10A
Insulin | 2 | A10AB01 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Lack of monitoring of blood glucose level | Hyperglycaemia or hypoglycaemia | Prolonged hospitalisation | 5 case reports | DPSD theme report 2007: [NAME] (5), 2007 Annual report – DPSD (68), 2008 Annual report – DPSD (69), Danish National Agency for Patients’ Rights and Complaints: Case no. 0553312, 0549807 (27)
Insulin | 2 | A10AB01 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Too high insulin dose prescribed in electronic medicine module | Hyperglycaemia | Prolonged hospitalisation (intravenous glucose) | 1 case report | 2009 Annual report – DPSD (42)
Insulin | 2 | A10AB01 | Errors in medication process (risk of administration of wrong medicine) | Adm./Disp. | Administration of wrong insulin product (e.g. Insulatard® instead of Actrapid®) | Hyperglycaemia or hypoglycaemia | Prolonged hospitalisation | 2 case reports | Danish National Agency for Patients’ Rights and Complaints: Case no.: 0341509, 0341513 (27)
Insulin | 1 | A10AB01 | Errors in medication process/patient errors (risk of dosage errors) | Prescr./Comp. | Interaction between insulin and other medicines causing ketoacidosis or hypoglycaemia | Hyperglycaemia or hypoglycaemia | Hospitalisation | Epidemiological studies | [NAME], 1990 (70), [NAME], 1986 (71)
Insulin and sulfonylurea | 1 | A10A and A10BB | Errors in medication process/patient errors (risk of dosage errors) | Prescr./Moni./Comp. | Hypoglycaemia where the patient has had repeated hypoglycaemic symptoms or has changed diet prior to hospitalisation. Hyperglycaemia due to too low dose prescribed or non-compliance. | Hyperglycaemia or hypoglycaemia | Not described | Epidemiological studies | [NAME], 2003 (72), [NAME], 2007 (73), Gurwitz et al., 2005 (53), [NAME] et al., 1996 (74), McDonnell et al., 2002 (75)
Insulin | 2 | A10AB01 | Errors in medication process (risk of dosage errors) | Not described | Overdosage of insulin and/or lack of monitoring of blood glucose | Hypoglycaemia | Prolonged hospitalisation; life-saving treatment | Epidemiological studies | Winterstein et al., 2002 (76), [NAME] 1992 (77), [NAME]. 1990 (78)
Insulin | 2 | A10AB01 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Inadequate monitoring of blood glucose level causing hypoglycaemia | Hypoglycaemia | Prolonged hospitalisation; life-saving treatment | Epidemiological studies | [NAME], 2004 (79)
Antithrombotics |  | B01
Warfarin | 1 | B01AA03 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Lack of monitoring of INR; lack of response to increased INR, interactions | Internal bleeding or seriously increased INR caused by lack of monitoring of INR, lack of response to increased INR or interaction with another medicine | Hospitalisation | Epidemiological study | Gurwitz et al., 2005 (53), [NAME], 2003 (80), Bigby et al., 1987 (81), [NAME] et al., 1996 (74), McDonnell et al., 2002 (75), [NAME], 1999 (82), [NAME], 2007 (73), [NAME], 1991 (83), Trunet et al., 1980 (84)
Warfarin | 1 (nursing homes) | B01AA03 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of monitoring of INR; lack of response to increased INR, interactions | Increased INR level or internal bleeding caused by interaction with another medicine, lack of monitoring of INR level or lack of response to increased INR level | Hospitalisation | Epidemiological study | Gurwitz et al., 2005 (53), [NAME], 2006 (85), [NAME], 2000 (86), Gurwitz et al., 2000 (87), [NAME] et [NAME]. 2007 (88)
Warfarin | 2 | B01AA03 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Reduction of warfarin dose | Resulted in clotted dialysis access | Re-hospitalisation | Epidemiological study | Boockvar et al., 2004 (89)
Warfarin | 2 (1) | B01AA03 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of monitoring of INR; lack of response to increased INR | Increased INR | Death (3 cases) | Epidemiological study | Kilbridge et al., 2006 (90)
Warfarin | 2 | B01AA03 | Not described | Not described | Not described | GI bleeding, haematuria, high INR, haematoma | Hospitalisation | Epidemiological study | Pirmohamed et al. 2004 (30)
Warfarin | 2 | B01AA03 | Errors in medication process (risk of dosage errors) | Prescr./Adm./Disp. | Mixing up weekly dose with daily dose | Overdosage causing risk of serious bleeding | Permanent injury/hospitalisation | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0019614 (27)
Warfarin | 2 | B01AA03 | Errors in medication process (risk of dosage errors) | [NAME]. | Doctor did not re-prescribe warfarin after suspicion of brain haemorrhage rejected | Cerebral thrombosis | Permanent injury/hospitalisation | 1 case report | 2007 Annual report – DPSD (68)
Warfarin | 2 | B01AA03 | Errors in medication process (risk of dosage errors) | [NAME]. | Patient stopped taking medicine due to misunderstanding between doctor and patient | Venous thrombosis | Permanent injury/hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Warfarin and heparins | 2 | [NAME] | Errors in medication process (risk of dosage errors) | Not described | Lack of or limited monitoring of INR | Overdosage causing haemorrhagic bleeding – minor (8 cases); serious (6 cases) | Life-saving treatment | Epidemiological studies | Winterstein et al., 2002 (51)
[NAME] |  | B01AA04 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Lack of or limited monitoring of INR (1 case); increased risk of fall accidents (1 case) | Large haematoma causing femoral nerve impairment (1); subdural haematoma (1) | Prolonged hospitalisation; life-saving treatment | Epidemiological studies | [NAME], 2004 (52)
Tinzaparin | 2 | B01AB10 | Errors in medication process (risk of dosage errors) | [NAME]. | Prescription not transferred from patient record to electronic medicine module | [NAME] embolism | Permanent injury/hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Tinzaparin | 2 | B01AB10 | Errors in medication process (risk of dosage errors) | [NAME]. | Not prescribed at discharge of patient – nursing home not notified | [NAME] embolism | Permanent injury/hospitalisation | 1 case report | 2007 Annual report – DPSD (68)
Tinzaparin | 2 | B01AB10 | Errors in medication process (risk of dosage errors) | Adm. | Lack of administration of tinzaparin | [NAME] embolism | Permanent injury/hospitalisation | 1 case report | 2009 Annual report – DPSD (42)
Tinzaparin | 2 | B01AB10 | Errors in medication process (risk of dosage errors) | [NAME]. | Not prescribed after surgery | [NAME] embolism | Permanent injuries/hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Tinzaparin | 2 | B01AB10 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Lack of monitoring | Development of haematoma requiring surgical treatment and transfusion | Life-saving treatment | Epidemiological studies | [NAME], 2004 (52)
Enoxaparin | 2 | B01AB05 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of prescription | Cerebral thrombosis | Permanent injury/hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Enoxaparin | 2 | B01AB05 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of discontinuation of enoxaparin after fall | Bleeding to death | Death | 1 case report | 2009 Annual report – DPSD (42)
Coagulation inhibitors |  | B01A
Acetylsalicylic acid |  | B01AC06 | Errors in medication process (risk of administration of wrong medicine) | Not described | Acetylsalicylic acid prescribed despite history of ulcers | Upper GI bleeding | Prolonged hospitalisation | Epidemiological studies | [NAME], 2004 (52), [NAME] 1992 (77),
Acetylsalicylic acid and clopidogrel | 1 | B01AC06 and B01AC04 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | GI bleeding or anaemia in patients with risk factors where bleeding could have been prevented by choosing enteric-coated tablets or other prophylaxis | GI bleeding | Hospitalisation | Epidemiological studies | [NAME], 1992 (91), [NAME], 2007 (73), [NAME], 2003 (72), Cannon et al., 1997 (92)
Clopidogrel | 2 | B01AC04 | Errors in medication process (risk of dosage errors) | Adm. | Took medicine from dosage box brought along – lack of discontinuation | Intra-abdominal bleeding | Permanent injury/hospitalisation | 1 case report | 2008 Annual report – DPSD (69)
Haemostatics |  | B02
Phytomenadione ([NAME]) | 2 | B02BA01 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of prescription at admission | Risk of brain haemorrhage | Hospitalisation/death | 2 case reports | 2008 Annual report – DPSD (69)
Anaemia |  | B03
Ferri-salts, injection fluid | 2 | B03AC02 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Five times stronger than prescribed concentration dispensed | Anaphylactic reaction | Prolonged hospitalisation | 1 case report | 2008 Annual report – DPSD (69)
Blood substitutes, solutions for infusion |  | B05
Potassium | 2 | B05BB02 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Solution for infusion six times stronger than prescribed | Overdosage causing life-threatening hyperkalaemia | Life-saving treatment/death | 1 case report | Danish National Agency for Patients’ Rights and Complaints: Case no. 0016730 (27)
Potassium | 2 | B05BB02 | Errors in medication process (risk of administration of wrong medicine) | Adm./Disp. | Potassium administered intravenously in a dose corresponding to oral administration | Overdosage causing life-threatening hyperkalaemia | Life-saving treatment/death | 1 case report | 2008 Annual report – DPSD (69), Danish National Agency for Patients’ Rights and Complaints, case no. Case no. 0020006 (27)
Potassium | 2 | B05BB02 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of dose reduction | Overdosage causing life-threatening hyperkalaemia | Life-saving treatment | 1 case report | 2009 Annual report – DPSD (42)
Glucose potassium phosphate | 2 | B05BB02 | Errors in medication process (risk of administration of wrong medicine) | Adm./ Disp. | Glucose potassium phosphate dispensed instead of glucose potassium | Cardiac arrhythmia | Not described | 1 case report | 2008 Annual report – DPSD (69)
Glucose | 2 | B05BA03 | Errors in medication process (risk of administration of wrong medicine) | Adm./ Disp. | 50% glucose dispensed instead of sodium chloride solution | Risk of hyperglycaemia | Not described | 1 case report | 2007 Annual report – DPSD (68)
Glucose | 2 | B05BA03 | Errors in medication process (risk of administration of wrong medicine) | Adm./ Disp. | Sodium infusion dispensed instead of glucose infusion | Mixing up products due to busyness | Risk of hypoglycaemia | 1 case report | DPSD theme report 2007: [NAME] (5)
Glucose | 2 | B05BA03 | Errors in medication process (risk of dosage errors) | Adm. | 500 ml 50% glucose administered in the course of a few minutes | Cardiac arrest | Life-saving treatment | 1 case report | 2008 Annual report – DPSD (69)
Phosphate | 2 | B05XA06 | Errors in medication process (risk of administration of wrong medicine) | Adm./ Disp. | Addiphos dispensed instead of allopurinol. Addiphos was administered undiluted | Cardiac arrest | Life-saving treatment | 1 case report | DPSD theme report 2007: [NAME] (5)
Digoxin |  | C01A
Digoxin | 2 | C01AA05 | Errors in medication process (risk of dosage errors) | [NAME]. | Patient prescribed 3 x 62.5 micrograms of digoxin, but when prescribing in electronic medicine module 3 x 650 micrograms was selected | Overdosage which may cause severe arrhythmia in the form of ventricular fibrillation, advanced AV block or asystole | Prolonged hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Digoxin | 2 | C01AA05 | Errors in medication process (risk of dosage errors) | [NAME]. | No monitoring of serum digoxin, thus no dose adjustment | Patient had pacemaker implanted | Hospitalisation | 2 case reports | DPSD theme report 2007: [NAME] (5); Danish National Agency for Patients’ Rights and Complaints: Case no. 0444869 (27)
Digoxin | 1 | C01AA05 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Not described | Toxic reaction with dizziness, confusion, anorexia, fainting, death caused by: Symptoms of digoxin poisoning (nausea, vomiting, anorexia) were missed, treatment not monitored by measuring renal function or blood digoxin level, or dosage far above recommended [NAME]. dose | Hospitalisation | Epidemiological studies | Gurwitz et al., 2005 (53), [NAME], 1990 (70), [NAME], 2003 (72), [NAME], 2001 (93), [NAME], 1992 (91), Bigby et al., 1987 (81), McDonnell et al., 2002 (75)
Digoxin | 1 | C01AA05 | Errors in medication process (risk of administration of wrong medicine) |  | Interaction between digoxin and spirolactone | Drug-to-drug interaction | Death | Epidemiological studies | Raschetti et al., 1999 (49)
Digoxin | 2(1) | C01AA05 | Errors in medication process (risk of dosage errors) | Not described | Not described | Overdosage causing digoxin intoxication | Hospitalisation, death | Epidemiological studies | Gurwitz et al., 2003 (94), [NAME]. 2004 (30), [NAME] 1992 (77)
Digoxin | 1 | C01AA05 | Errors in medication process (risk of dosage errors) | Not described | Digoxin overdosage | Toxic reaction to increased digoxin dose, which caused death | Death | Epidemiological studies | Gurwitz et al., 2005 (53)
Antiarrhythmic agents |  | C01B |  |  |  |  |  | Epidemiological studies
Amiodarone | 2 | C01BD01 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Wrong dose dispensed/misadjustment of drop counter | Overdosage which may cause fatal bradycardia and QT prolongation | Life-saving treatment/death | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0761803 (27), DPSD theme report 2007: [NAME] (5)
Lidocaine | 2 | C01BB01 | Errors in medication process (risk of dosage errors) | Not described | Overdosage | Overdosage – increased serum lidocaine concentration causing bradycardia and asystole | Death | Epidemiological studies | Nebecker et al., 2005 (54)
Cardiovascular stimulating agents |  | [NAME]
Epinephrine (adrenaline) |  | C01CA24 | Errors in medication process (risk of administration of wrong medicine) | Adm./Disp. | Mixing up epinephrine (adrenaline) and lidocaine | Myocardial infarction. | Life-saving treatment/death | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0125906 (27)
Epinephrine (adrenaline) | 2 | C01CA24 | Errors in medication process (risk of administration of wrong medicine) | Adm./Disp. | Adrenalin dosed and administered instead of heparin | Cardiac arrest | Life-saving treatment/death | 1 case report | 2008 Annual report – DPSD (69)
Norepinephrine (noradrenaline) | 2 | C01CA03 | Errors in medication process (risk of dosage errors) | Adm. | Pump with noradrenalin inflow turned off – causing destabilisation | Risk of cardiac arrest | Life-saving treatment/death | 1 case report | 2008 Annual report – DPSD (69)
Norepinephrine (noradrenaline) | 2 | C01CA03 | Errors in medication process (risk of dosage errors) | Adm. | Administration, unintentional closing of three-way valve resulting in underdosage | Risk of cardiac arrest | Life-saving treatment/death | 2 case reports | DPSD theme report 2007: [NAME] (5), 2008 Annual report – DPSD (69)
Short-acting nitrates |  | C01DA
[NAME] nitrate | 2 | C01DA02 | Errors in medication process (risk of dosage errors) | Adm. | Too high dose administered due to too high infusion rate | Cardiac arrest | Life-saving treatment/death | 1 case report | DPSD theme report 2007: [NAME] (5)
Diuretics |  | C03
Diuretics | 1 | C03 | Errors in medication process/patient errors (risk of dosage errors) | Prescr./Moni./Comp. | Lack of monitoring of electrolytes resulting in electrolyte disturbances in the form of hypokalaemia or hyponatraemia, orthostatic hypotension, dehydration, renal insufficiency, dizziness, constipation | Not described | Hospitalisation | Epidemiological studies | [NAME], 2007 (73), [NAME], 1986 (71), [NAME], 2003 (72), [NAME], 1990 (70), [NAME], 1991 (95), Bigby et al., 1987 (81), [NAME] et al., 1996 (74), Cannon et al., 1997 (92), [NAME], 1999 (82), Trunet et al., 1980 (84)
Diuretics | 1 | C03 | Errors in medication process/patient errors (risk of dosage errors) | Moni./Comp. | Lack of therapeutic effect caused by underdosage or non-compliance | Cardiac arrest | Hospitalisation | Epidemiological studies | [NAME], 2003 (72), [NAME], 1990 (78), [NAME], 1991 (95), Gurwitz et al., 2005 (53)
Diuretics | 1 (nursing homes) | C03 | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Electrolyte disturbances or lack of therapeutic effect caused by lack of monitoring or lack of response to electrolyte levels | Not described | Hospitalisation | Epidemiological studies | Gurwitz et al., 2005 (53), [NAME], 2006 (85), [NAME], 2006 (96), Ruths et al., 2003 (97), [NAME], 2000 (86)
Thiazides | 2 | C03AA | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of follow-up | Serum sodium below 130 mmol/l. Risk group (elderly patients) | Hospitalisation | Epidemiological studies | [NAME] et al., 2004 (98)
Furosemide | 2 | C03CA01 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of prescription/prescription not transferred to electronic medicine module | Not described | Cardiac incompensation | 1 case report | DPSD theme report 2007: [NAME] (5)
Beta-receptor blocking agents |  | C07
Metoprolol | 2 | C07AB02 | Errors in medication process (risk of dosage errors) | [NAME]. | Too rapid dose increase | Bradycardia and hypotension | Prolonged hospitalisation | Epidemiological studies | [NAME], 2004 (79), [NAME]. 2004 (30)
Metoprolol | 2 | C07AB02 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of prescription at discharge | Bradycardia and hypotension |  | 1 case report | DPSD theme report 2007: [NAME] (5)
Calcium antagonists |  | C08
Nifedipine | 2 | C08CA05 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Parents received incorrect instruction on dosage quantity – child overdosed | Increased observation | Hospitalisation | 1 case report | 2009 Annual report – DPSD (42)
Nifedipine | 2 | C08CA05 | Errors in medication process (risk of dosage errors) | Adm. | Wrong dose dispensed, causing overdosage | Hypotension | Not described | 1 case report | 2009 Annual report – DPSD (42)
Corticosteroids for systemic use |  | H02A
Prednisolone | 1 | H02AB06 | Pharmacology | [NAME]. | Osteoporosis caused by prednisolone without prescribed prophylaxis | Long-term users of prednisolone | Permanent injuries | Epidemiological studies | [NAME], 2007 (73), [NAME] et al., 1996 (74)
Prednisolone | 2 | H02AB06 | Not described | Not described | Not described | Gastritis, GI bleeding, hyperglycaemia, osteoporotic fractures | Hospitalisation | Epidemiological studies | Pirmohamed et al., 2004 (30)
Thyroid hormones |  | H03A
Levothyroxine | 2 | H03AA01 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of prescription of Eltroxin at admission | Tachycardia | Hospitalisation | 1 case report | 2007 Annual report – DPSD (68)
Antibacterials for systemic use |  | J01
Antibiotics | 1 | J01 | Errors in medication process | [NAME]. | Antibiotics prescribed despite known patient allergy | Allergic reaction | Hospitalisation | Epidemiological studies | [NAME] et al., 2003 (99), Gurwitz et al., 2005 (53), [NAME], 1999 (82), [NAME], 2001 (93)
Antibiotics | 2 | J01 | Errors in medication process | Not described | Antibiotics prescribed despite known allergy | Rash (1 case), allergy | Prolonged hospitalisation | Epidemiological studies | [NAME], 2001 (50)
Penicillin | 2 | [NAME] | Errors in medication process (risk of dosage errors) | Disp. | Too late dispensing of penicillin | Sepsis | Respiratory failure | 2 case reports | DPSD theme report 2007: [NAME] (5)
Penicillin | 2 | [NAME] | Errors in medication process (risk of dosage errors) | [NAME]. | Mixing up grams with micrograms | Not described | Liver damage | 1 case report | 2009 Annual report – DPSD (42)
Ciprofloxacine | 2 | J01MA02 | Errors in medication process (risk of dosage errors) | [NAME]. | [NAME]. not approved in electronic medicine module | Not described | Cystitis | 1 case report | 2008 Annual report – DPSD (69)
Gentamicin | 2 | J01GB03 | Errors in medication process (risk of dosage errors) | [NAME]. | Prescription does not take into account serum gentamicin level, resulting in gentamicin overdosage | Kidney damage, most often reversible | Prolonged hospitalisation | 2 case reports | DPSD theme report 2007: [NAME] (5)
Gentamicin | 2 | J01GB03 | Errors in medication process (risk of dosage errors) | Adm. | Double administration at two different times | Kidney damage, most often reversible | Prolonged hospitalisation | 1 case report | DPSD theme report 2007: [NAME] (5)
Nevirapine | 2 | J05A | Errors in medication process/patient errors | Adm./Comp. | Patient misunderstood information about reduced dosage during first two weeks. Instead patient took normal maintenance dose, which is twice as high as prescribed dose. | Overdosage may cause severe liver damage | Death | 1 case report | [NAME], 2005 (100)
Ceftriaxone | 2 | J01DD04 | Errors in medication process (risk of administration of wrong medicine) | [NAME]. | Choice of wrong antibiotics – known previous reaction of thrombopenia associated with ceftriaxone | Thrombopenia | Prolonged hospitalisation/life-saving treatment | Epidemiological studies | [NAME], 2004 (79)
Amoxicillin | 2 | J01CR02 | Errors in medication process (risk of administration of wrong medicine) | [NAME]. | Prescription of amoxicillin despite known allergy to the medicine | Rash and oedemas | Prolonged hospitalisation | Epidemiological studies | [NAME], 2004 (79)
Cefuroxime | 2 | [NAME] | Errors in medication process (risk of administration of wrong medicine) | Adm. | Administration despite known allergy to the medicine | Quincke’s oedema | Not described | 1 case report | DPSD theme report 2007: [NAME] (5)
Cefuroxime | 2 | [NAME] | Errors in medication process | Adm. | Administered several hours after time prescribed for | Not described | Sepsis | 1 case report | 2007 Annual report – DPSD (68)
Cefuroxime | 2 | [NAME] | Errors in medication process (risk of administration of wrong medicine) | [NAME]. | Cefuroxime prescribed instead of ciprofloxacine | Not described | Contracted pneumonia | 1 case report | DPSD theme report 2007: [NAME] (5)
Cytostatics |  | L01
Methotrexate | 2 | L01BA01 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Mixing up daily dose and weekly dose resulting in overdosage | Overdosage causing severe immunosuppression. | Prolonged hospitalisation | 7 case reports | DPSD theme report 2007: [NAME] (5), 2007 Annual report – DPSD (68), 2008 Annual report – DPSD (69), 2009 Annual report – DPSD (42), Danish National Agency for Patients’ Rights and Complaints, case no. 0021501, 0124628, 0127721 (27)
Methotrexate | 2 | L01BA01 | Errors in medication process (risk of dosage errors) | [NAME]. | Wrong prescription/too high daily dose | Overdosage causing severe immunosuppression. | Prolonged hospitalisation | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0343401 (27)
Methotrexate | 2 | L01BA01 | Errors in medication process (risk of dosage errors) | [NAME]. | Full dose prescribed disregarding white blood cell count | Bone marrow depression | Hospitalisation | 1 case report | 2009 Annual report – DPSD (42)
5-Fluoruracil | 2 | L01BC02 | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of reduction in prescription in connection with concomitant radiation treatment | Stomatitis | Not described | 1 case report | DPSD theme report 2007: [NAME] (5)
Etoposide | 2 | L01CB01 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Incorrectly administering undiluted concentrate which was 100 times stronger than prescribed quantity (100 mg instead of 1 mg). | Apathy with lack of visual and hearing ability | Not described | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0872210 (27)
Daunorubicin | 2 | L01DB02 | Errors in medication process (risk of dosage errors) | [NAME]. | Full dose prescribed to patients with renal impairment | Renal insufficiency | Not described | 3 case reports | 2007 Annual report – DPSD (68)
Carboplatin | 2 | L01XA02 | Errors in medication process (risk of dosage errors) | [NAME]. | Full dose prescribed disregarding white blood cell count | Septic shock | Not described | 1 case report | 2007 Annual report – DPSD (68)
Carboplatin | 2 | L01XA02 | Errors in medication process (risk of dosage errors) | Adm. | Dose was not reduced but full dose was administered | Sepsis | Not described | 1 case report | DPSD theme report 2007: [NAME] (5)
Non-steroidal anti-inflammatory drugs (NSAIDs) |  | [NAME]
NSAID | 2 | [NAME] | Errors in medication process (risk of administration of wrong medicine) | [NAME]. | Prescription of NSAIDs to patients with history of ulcers without concomitant prescription of proton pump inhibitor | Development of ulcers | Permanent injury/hospitalisation | 1 case report | Danish National Agency for Patients’ Rights and Complaints: Case no. 0550726 (27)
NSAID | 1 | [NAME] | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Overdosage, unnecessary treatment, or cases where prescription of prophylaxis could have prevented bleeding in patients with one or more known risk factors | GI bleeding | Hospitalisation | Epidemiological studies | [NAME], 2003 (72), [NAME], 2007 (73), Gurwitz et al., 2005 (53), [NAME], 1992 (91), [NAME] et al., 1996 (74), [NAME], 1999 (82)
NSAIDs + heparin analogues | 2 | [NAME] | Errors in medication process (risk of administration of wrong medicine) | Not described | Inappropriate interaction between NSAID and heparin | Upper GI bleeding (1 case); aspiration (1 case); acute myocardial infarction (1 case) | Death (3 cases) | Epidemiological studies | Nebecker et al., 2005 (54)
Peripherally acting muscle relaxants
Suxamethonium | 2 | M03AB01 | Errors in medication process (risk of administration of wrong medicine) | Disp. | Mixing up lidocaine with suxamethonium | Artificial ventilation required | Emergency life-saving treatment (ventilation) required | 1 case report | 2006 Annual report – DPSD (101)
Suxamethonium | 2 | M03AB01 | Errors in medication process (risk of administration of wrong medicine) | Disp. | Mixing up fentanyl with suxamethonium | No respiration | Emergency life-saving treatment (ventilation) required | 1 case report | 2006 Annual report – DPSD (101)
General anaesthetics |  | N01A
Thiopental | 2 | N01AF03 | Errors in medication process (risk of dosage errors) | Adm./Disp. | An infusion mixture five times too strong made by mistake | Overdosage causing apnoea and severe hypotension | Life-saving treatment, respiratory depression | 1 case report | DPSD theme report 2007: [NAME] (5)
Propofol | 2 | N01AX10 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Double dose administered. Believed that unlabelled syringe contained 10 mg/ml, but it contained 20 mg/ml. | Cardiac arrest | Life-saving treatment; cardiac arrest | 1 case report | 2008 Annual report – DPSD (69)
[NAME] and strong opioids |  | N02A
[NAME] | 2 | N02A | Errors in medication process (risk of dosage errors) | Adm./Disp. | Decimal error when administering morphine (mg translated into ml) – too high dose administered | Overdosage | Life-saving treatment | 1 case report | DPSD theme report 2007: [NAME] (5)
[NAME] and strong opioids | 2 | N02A | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of dose reduction for elderly | Overdosage (impaired consciousness/respiratory arrest). | Life-saving treatment/death | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0761608 (27)
[NAME] and strong opioids | 2 | N02A | Errors in medication process (risk of dosage errors) | Not described | Not described | Overdosage causing apnoea | Death | Epidemiological studies | Nebecker et al., 2005 (54)
Opioids | 1 | N02A | Errors in medication process (risk of dosage errors) | [NAME]. | Overdosage causing stupor |  | Hospitalisation | Epidemiological studies | [NAME], 1990 (78), [NAME], 2007 (73)
Opioids | 1 | N02A | Errors in medication process (risk of dosage errors) | [NAME]. | Laxatives not prescribed concomitantly with opiod treatment | Constipation and possibly vomiting | Hospitalisation | Epidemiological studies | Forster et al., 2003 (80)
Opioids | 2 | N02A | Errors in medication process (risk of dosage errors) | Not described | Overdosage | Sedation/somnolence, rash, respiratory arrest/respiratory depression, seizures | Prolonged hospitalisation; life-saving treatment | Epidemiological studies | Winterstein et al., 2002 (51)
Opioids | 2 | N02A | Errors in medication process (risk of dosage errors) | Not described | Overdosage causing death | Overdosage | Death | Epidemiological studies | Kilbridge et al., 2006 (90)
Opioids | 2 | N02A | Errors in medication process (risk of dosage errors) | Not described | Overdosage/underdosage | Extreme sedation (overdosage); pains (probably caused by underdosage) | Prolonged hospitalisation | Epidemiological studies | [NAME], 2001 (50)
[NAME] | 2 | N02AA01 | Errors in medication process (risk of dosage errors) | Adm. | Communication error | Overdosage – dose ten times too high injected subcutaneously | Respiratory depression | 1 case report | 2008 Annual report – DPSD (69)
[NAME] | 2 | N02AA01 | Errors in medication process (risk of dosage errors) | Adm. | Incorrect administration | Not described | Respiratory depression | 1 case report | DPSD theme report 2007: [NAME] (5)
Oxycodone | 2 | N02AA05 | Errors in medication process (risk of dosage errors) | Adm. | Lack of identification of patient/took other patient’s medicine | Increased monitoring and treatment (active coal) | Respiratory depression | 1 case report | 2008 Annual report – DPSD (69)
Oxycodone | 2 | N02AA05 | Errors in medication process (risk of dosage errors) | [NAME]. | Prescribed despite contraindication | Transferred to intensive care unit | Respiratory depression | 1 case report | 2007 Annual report – DPSD (68)
Oxycodone | 2 | N02AA05 | Errors in medication process (risk of dosage errors) | [NAME]. | Too high dose prescribed in relation to age | Not described | Respiratory depression (treated using ventilation bag) | 1 case report | DPSD theme report 2007: [NAME] (5)
Antiepileptics |  | N03A
Antiepileptics | 1 | N03A | Errors in medication process (risk of dosage errors) | Prescr./Moni./Comp. | Lack of monitoring or non-compliance causing toxic reactions or epileptic seizures | Overdosage or underdosage | Hospitalisation | Epidemiological studies | [NAME], 2003 (72), [NAME], 1986 (71), [NAME], 2007 (73), [NAME] et al., 1996 (74), McDonnell et al., 2002 (75), [NAME], 1990 (78)
Fosphenytoin | 2 | N03AB05 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Product incorrectly administered as continuous infusion instead of bolus injection | Overdosage (cardiac arrest). | Life-saving treatment/death | 1 case report | DPSD theme report 2007: [NAME] (5)
Phenobarbital | 2 | N03AA02 | Errors in medication process (risk of dosage errors) | Adm. | Patient not observed/too high dose administered | Suicidal patient was prescribed 100 tablets | Respiratory depression | 1 case report | 2008 Annual report – DPSD (69), Danish National Agency for Patients’ Rights and Complaints, case no. 9912613 (27)
Phenobarbital | 1 | N03AA02 | Errors in medication process (risk of dosage errors) | [NAME]. | Underdosage | Patient was prescribed 15 mg instead of 100 mg | Hospitalisation due to several seizures | 1 case report | Danish National Agency for Patients’ Rights and Complaints, case no. 0765410 (27)
Antipsychotics |  | N05A
Antipsychotics | 1 | N05A | Errors in medication process (risk of dosage errors) | [NAME]. | Overdosage or treatment lasting several years never reconsidered | Toxic reaction, adverse reactions or death | Hospitalisation | Epidemiological studies | [NAME], 1991 (95), [NAME], 2007 (73)
Antipsychotics | 1 (nursing homes) | N05A | Errors in medication process (risk of dosage errors) | [NAME]. | Unnecessary medication, overdosage or used in connection with non-psychiatric diagnoses | Anticholinergic, extrapyramidal and neuropsychiatric adverse reactions | Hospitalisation | Epidemiological studies | Gurwitz et al., 2005 (53), [NAME], 1999 (102), [NAME], 2000 (86), [NAME], 2006 (96), Ruths et al., 2003 (97)
Antipsychotics |  | N05A | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Prescription for elderly patients without justified indication, lack of follow-up and discontinuation | Increased risk of death due to prescription of antipsychotics. Risk groups (elderly and patients with dementia) | Death/permanent injury | Epidemiological studies | Ballard et al., 2006 (103), [NAME], 2009 (104), [NAME] et al., 2005 (105)
Zuclopenthixol | 2 | N05AF05 | Errors in medication process (risk of dosage errors) | [NAME]. | Prescribed in the electronic medicine module as tablets and not as mg | Not described | Impaired consciousness level | 1 case report | 2007 Annual report – DPSD (68)
Quetiapine | 2 | [NAME] | Errors in medication process (risk of dosage errors) | Adm. | Took another patient’s medicine | Not described | Cardiac poisoning symptoms | 1 case report | 2009 Annual report – DPSD (42)
[NAME] | 2 | N05AD01 | Errors in medication process (risk of dosage errors) | Adm./ Disp. | Too high dose dispensed | Overdosage | Sedated | 1 case report | DPSD theme report 2007: [NAME] (5)
Benzodiazepines |  | N05BA
Benzodiazepines | 1 | N05BA | Errors in medication process/patient errors | Prescr./Comp. | Excessive use by patient or too high dose prescribed | Toxic reaction such as sedation | Hospitalisation | Epidemiological studies | [NAME], 1990 (78), [NAME], 2003 (80)
Benzodiazepines | 1 (nursing homes) | N05BA | Errors in medication process (risk of dosage errors) | [NAME]. | Overdosage or unnecessary medication | Oversedation, fall, immobility | Hospitalisation | Epidemiological studies | Gurwitz et al., 2005 (53), [NAME], 2006 (85), [NAME], 2006 (96), Ruths et al., 2003 (97), [NAME] et [NAME], 2007 (88)
[NAME] | 2 | [NAME] | Errors in medication process (risk of dosage errors) |  | Oversedation | Respiratory insufficiency | Prolonged hospitalisation | Epidemiological studies | [NAME], 2004 (79)
[NAME] | 2 | [NAME] | Errors in medication process (risk of dosage errors) | Adm. | Overdosage due to mixing up of inlet rate for midazolam and glucose solutions for infusion | Impaired consciousness level | Somnolent for several days | 1 case report | 2009 Annual report – DPSD (42)
Triazolam | 2 | N05CD05 | Errors in medication process (risk of dosage errors) | [NAME]. | Prescription despite chronic lung disease, do not prescribe (CAVE) instruction bypassed | Not described | Severe anoxia | 1 case report | 2007 Annual report – DPSD (68)
Antidepressants |  | N06A
Antidepressants | 1 (nursing homes) | N06A | Errors in medication process (risk of dosage errors) | Prescr./Moni. | Unnecessary treatment, medicine interactions or lack of monitoring | Pronounced adverse reactions | Hospitalisation | Epidemiological studies | [NAME], 2006 (96), Ruths et al., 2003 (97)
SSRIs | 2 | N06AB | Errors in medication process (risk of dosage errors) | [NAME]. | Lack of follow-up | Serum sodium below 130 mmol/l | Hospitalisation | Epidemiological studies | [NAME] et al., 2004 (98)
Other drugs for central nervous system disorders |  | N07
Methadone | 2 | N07BC02 | Errors in medication process (risk of dosage errors) | Adm. | Lack of identification of patient/took other patient’s medicine | Not described | Respiratory depression | 2 case reports | DPSD theme report 2007: [NAME] (5), 2007 Annual report – DPSD (68)
Other therapeutic products |  | V03A
Acetylcysteine | 2 | V03AB23 | Errors in medication process (risk of dosage errors) | Adm./Disp. | Solution for infusion ten times stronger than prescribed | Cardiac arrest. | Life-saving treatment/death | 1 case report | DPSD theme report 2007: [NAME] (5)
Sodium polystyrene sulfonate | 2 | V03AE01 | Errors in medication process (risk of dosage errors) | Adm. | Did not take dose, resulting in hyperkalaemia | Cardiac arrest. | Life-saving treatment/death | 1 case report | 2009 Annual report – DPSD (42)