Type of incident

Number

Description

Unlabelled drug

2

Unlabelled morphine used to dilute antibiotics

Syringe swap

3

Drugs given mistakenly as Antibiotics:

Morphine, Rocuronium, Phenylephrine

Drug or ampoule substitution

6

Ergometrine for syntocinon

Ephedrine for heparin for arterial line infusion

Naloxone for maxolon (similar name)

Naloxone for dexamethasone

Protamine for tranexamic acid (similar ampoule)

Ondansetron for epidural fentanyl

Patient with drug allergy

5

Drug was given to allergic patient

4 involving antibiotics and 1 non-steroidal anti-inflammatory drug

Others

2

Suxamethonium in a patient with recent cervical spine injury

Administration of both Naproxen and Arcoxia to a patient (prescriber did not check previous drugs)