Table 3

 Examples of prescribing and administration errors identified

IV, intravenous.
Prescribing errors (stage of drug use process)
• Patient usually takes simvastatin 20 mg at night, but not prescribed on admission (need for drug treatment)• Tinzaparin and enoxaparin prescribed together when only one was needed (need for drug treatment)
• “Vitamin B12 co strong” prescribed when “vitamin B tablets compound strong” intended (select specific drug)• Cyclizine 50 mg tablets prescribed to be given once an hour, instead of once every 8 h, when required (select drug dose)
• Bendroflumethiazide 20 mg once daily prescribed when 5 mg intended (select drug dose)• A dose of ciclosporin 150 mg was prescribed to be given using the 100 mg capsules rather than the 50 mg capsules (select formulation)
• Dipyridamole 200 mg twice daily prescribed for secondary prevention of ischaemic stroke, without specifying that modified release required (select formulation)• Trimipramine 50 mg four times daily prescribed for a patient who usually takes 200 mg at night (give administration instructions)
• Beclometasone inhaler prescribed with no strength specified (give instructions for supply)
• Prednisolone 10 mg prescribed without specifying time or frequency of administration (give administration instructions)
Administration errors (type of error)
• Levothyroxine 25 μg omitted as could not find medication (omission)• Propranolol 160 mg not given as not available on ward (omission due to unavailability)
• Thiamine 100 mg prescribed. Observer intervened to prevent levothyroxine 100 μg being given (wrong drug)• Salbutamol 5 mg nebule administered when 2.5 mg prescribed (wrong dose)
• Ciprofloxacin 500 mg administered when 250 mg prescribed (wrong dose)• Administration of Tazocin 4.5 g IV over 30 s instead of 3–5 min (fast administration IV bolus)
• Norfloxacin 400 mg given twice as first dose was not signed for (extra dose)• Administration of paracetamol 1 g orally when rectal route was prescribed (wrong route)