Table 5 Top 20 interventions of 123 interventions implemented

1. double-checking of vasoactive drugs

11. purchase carts for nurses to prepare medicines at patients’ bedsides

2. double-checking of insulin

12. reminder implemented to avoid loss of drugs in the transfer between units

3. double-checking of multi-dose psychoactive medications

13. morphine doses greater than 6 mg prepared exclusively by pharmacy

4. double-checking of medications administered via infusion pump at the time of administration

14. sound and look alike drugs stored in different places

5. packaging of sterile petroleum jelly from ampoules to refillable bottle to prevent erroneous intravenous administration

15. high box use (capital letters) in the bar code identification and in the medical prescription and in the prescription for the medications sound alike look alike (ETILEfrine vs EPINEPHrine)

6. reminder was implemented to perform medication reconciliation when patients were transferred between units

16. Require prescription of drugs in doses rather than unit (tablet, vial, ampoule)

7. double checking medical prescription between nurses during shift changes

17. patient education for the conference identification bracelet with prescription at the time of drug administration

8. standardization in the medical team to change drug infusion rates

18. reinforcement for nursing staff for the immediate return of drugs suspended

9. reminder implemented for patient allergy insertion into the prescription form

19. change the color label for compounded drugs

10. insertion into prescription by pharmacist the diluent volume and rate of infusion of medications that may cause phlebitis

20. challenge units to increase reporting of medication errors