Table 1

Sample prescription errors

Erroneous prescriptionError categoryResolution
IV morphine rate changed from 0.015 to 0.1 mg/kg/hUnitsOverdose based on formulary. MD changed dose to 0.01 mg/kg/h
IV midazolam rate change from 0.1 to 0.9 mg/kg/hUnitsMD intended rate change to 0.09 mg/kg/h
Rotavirus live vaccine 2 ml IM ×1RouteMD changed order to PO route
IV hydromorphone 0.06 mg/kg/hFormularyOverdose based on formulary. Dose corrected to 0.006 mg/kg/h
IV cefotaxime 250 mg every 12 hMonitoringDosing decreased to 125 mg due to declining renal function
Hepatitis B vaccine IM ×1Duplicate therapyPatient previously received vaccine. Order discontinued
  • Sample errors taken from feedback emails over the course of the program.

  • h, hour; IM, intramuscular; IV, intravenous; kg, kilogram; MD, doctorate of medicine; mg, milligram; ml, milliliter.