Table 2

 Summary of main findings for unintended variances

Overall(N = 60)Admission(N = 60)Discharge(N = 56)
No of patients with at least one unintended variance (%, 95% CI)36 (60%, 48 to 72)23 (38%, 26 to 51)23 (41%, 28 to 54)
Mean number of unintended variances per patient (95% CI)2.3 (1.5 to 3)1.2 (0.7 to 1.6)1.2 (0.7 to 1.7)
Types of unintended variances (% of variances)
    Total number of unintended variances136 (100%)69 (100%)67 (100%)
    Omitted medication/prescription80 (59%)50 (72%)30 (45%)
    Incorrect/omitted details (dose, route, frequency)18 (13%)15 (22%)3 (4%)
    Additional medication unintentionally ordered4 (3%)4 (6%)0
    Lack of discharge instruction regarding medication changed in hospital34 (25%)NA34 (51%)
No of patients with at least one clinically important unintended variance (%, 95% CI)11 (18%, 9 to 28)9 (15%, 6 to 24)5 (9%, 2 to 16)
Clinically important unintended variances201010
    Intercepted1587
    Not intercepted523
Variances leading to harm422
Physician response to unintended variance
    Order new medication/prescription21 (15%)2 (3%)19 (28%)
    Discontinue or hold medication3 (2%)1 (1%)2 (3%)
    Change details (e.g. dose, route, frequency)11 (8%)7 (10%)4 (6%)
    Restart medication31 (23%)22 (32%)9 (13%)
    No changes made70 (51%)37 (54%)33 (49%)
    Total1366967