Table 2

Situations that should be included as prescribing errors

Results
ScenarioRound 1*Round 2*Code†
*Figures refer to the lower limit of the interquartile range, the median score (in bold), and the upper limit of the interquartile range.
†C = consensus; P = partial agreement; I = include as a prescribing error; EQ = equivocal.
‡Originally worded as “prescribing a drug for which there is no documented indication for that patient”. However, the judges considered that a prescribing error had not occurred if an indication existed but was not documented, while prescribing where no indication existed was considered a prescribing error. The word “documented” was therefore removed and the scenario included as a prescribing error.
Errors in decision making
Prescription inappropriate for the patient concerned
Prescribing a drug for a patient for whom, as a result of a co-existing clinical condition, that drug is contraindicated8, 9, 9N/AC, I
Prescription of a drug to which the patient has a documented clinically significant allergy8, 9, 9N/AC, I
Not taking into account a potentially significant drug interaction7, 8, 9N/AC, I
Prescribing a drug in a dose that, according to British National Formulary or data sheet recommendations, is inappropriate for the patient's renal function7, 8, 9N/AC, I
Prescription of a drug in a dose below that recommended for the patient's clinical condition5, 7, 86, 7, 7C, I
Prescribing a drug with a narrow therapeutic index, in a dose predicted to give serum levels significantly above the desired therapeutic range6, 7, 8.257, 8, 8C, I
Writing a prescription for a drug with a narrow therapeutic range in a dose predicted to give serum levels significantly below the desired therapeutic range3.75, 7, 86, 7, 7,25C, I
Not altering the dose following steady state serum levels significantly outside the therapeutic range5, 7, 97, 7, 8C, I
Continuing a drug in the event of a clinically significant adverse drug reaction6.5, 8, 97, 8, 8.25C, I
Prescribing two drugs for the same indication when only one of the drugs is necessary5.75, 7, 86, 7, 8C, I
Prescribing a drug for which there is no indication for that patient‡5, 7, 85, 6, 7C, EQ
Pharmaceutical issues
Prescribing a drug to be given by intravenous infusion in a diluent that is incompatible with the drug prescribed8, 9, 9N/AC, I
Prescribing a drug to be infused via an intravenous peripheral line, in a concentration greater than that recommended for peripheral administration6, 8, 97, 8, 8C, I
Errors in prescription writing
Failure to communicate essential information
Prescribing a drug, dose or route that is not that intended9, 9, 9N/AC, I
Writing illegibly5, 8, 97, 8, 9C, I
Writing a drug's name using abbreviations or other non-standard nomenclature6, 7, 97, 7, 8.25C, I
Writing an ambiguous medication order6, 7.5, 97, 8, 9C, I
Prescribing “one tablet” of a drug that is available in more than one strength of tablet6, 7.5, 97, 8, 9C, I
Omission of the route of administration for a drug that can be given by more than one route6, 8, 97, 8, 9C, I
Prescribing a drug to be given by intermittent intravenous infusion, without specifying the duration over which it is to be infused5, 6, 85, 7, 8P, I
Omission of the prescriber's signature5, 8, 95.75, 8, 9P, I
Transcription errors
On admission to hospital, unintentionally not prescribing a drug that the patient was taking prior to their admission7, 8, 9N/AC, I
Continuing a GP's prescribing error when writing a patient's drug chart on admission to hospital7.75, 8.5, 9N/AC, I
Transcribing a medication order incorrectly when rewriting a patient's drug chart8, 9, 9N/AC, I
Writing “milligrams” when “micrograms” was intended9, 9, 9N/AC, I
Writing a prescription for discharge medication that unintentionally deviates from the medication prescribed on the inpatient drug chart8, 9, 9N/AC, I
On admission to hospital, writing a medication order that unintentionally deviates from the patient's pre-admission prescription6, 9, 97, 9, 9C, I