Table 4

Examples of errors identified

Potentially serious prescribing errorsLess serious prescribing errors
An elderly patient was prescribed 10 ml IV diazepam (equivalent to 50 mg) to be given when required, instead of the intended 10 mg.A patient already taking lansoprazole 30 mg daily was additionally prescribed ranitidine 150 mg twice daily.
Captopril 250 mg twice daily was prescribed when 25 mg twice daily was intended.Beclomethasone inhaler was prescribed without specifying the intended strength (100 mu;g per inhalation).
A patient had a phenytoin level of 5.5 mg/l on a dose of 350 mg daily. The dose was erroneously reduced to 120 mg daily.A patient was prescribed 20 mg lansoprazole daily when 30 mg was intended. Capsules are available only as 15 mg or 30 mg strengths.
A patient was prescribed metoclopramide 10 mg 8 hourly on each of his 3 drug charts, resulting in the patient receiving 90 mg daily until the pharmacist intervened.Isosorbide dinitrate was prescribed instead of isosorbide mononitrate.
Intravenous ranitidine 50 mg tds was inadvertently omitted for a critically ill patient with peptic ulcer disease whose drug chart was rewritten.Glyceryl trinitrate was prescribed without specifying the dose or formulation to be administered.
Sustained release nifedipine 20 mg daily prescribed when 20 mg twice daily was intended.