Teunissen et al identified risk factors for errors in the time of drug administration. A drug taken at a different time than prescribed can interact with food or other drugs and can result in lower than intended drug levels at a specified time. The authors are from Canisius-Wilhelmina Ziekenhuis in Nigmegen, The Netherlands.


A medication administration time error is the administration of a drug dose:

(1) more than 1 hour before OR

(2) more than 1 hour after the time prescribed.


Administration time errors were the most common type of medication error that occurred.


Risk factors for administration time errors:

(1) during early morning ("7 AM") rounds

(2) rectal or inhalation route of administration (rectal administration was put off to last)

(3) leaving the pill at the bedside (not requiring the dose to be taken immediately)

(4) Friday (Weekends were not included in study but usually staffing is lower. Holidays also may be associated with low staffing but also fewer patients.)


Factors associated with a low rate of administration time errors:

(1) dosing at noon and afternoon

(2) injection or infusion

(3) drug prescribed "if necessary"

(4) surgery ward


While administration time errors are often considered innocuous they can be significant.


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