Examples of prescribing and administration errors identified
| Pre-intervention | Post-intervention |
|---|---|
| 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) |