Table 4

Top 10 errors occurring pre-CPOE and post-CPOE implementation across all sites

Prescribing errorPre-CPOEPost-CPOE
RankNOpp NErr Error rate (%)RankNOpp NErr Error rate (%)
Regular opiates prescribed without concurrent use of laxatives (risk of severe constipation)14865511.33438378.4
Benzodiazepines prescribed long term (ie, more than 2–4 weeks) (risk of dependence and withdrawal reactions)21294031.021223831.1
Digoxin prescribed concomitantly with a diuretic (risk of hypokalaemia and subsequent digoxin toxicity)3763951.35592542.4
Insulin prescribed to a patient at an inappropriate time, allowing for an administration without food (except once-daily long-acting insulins) (increased risk of hypoglycaemia)41042826.911135044.2
Citalopram prescribed concomitantly with other QT-prolonging drugs (increased risk of arrhythmias)51612817.481411913.5
Clopidogrel prescribed to a patient concomitantly with omeprazole or esomeprazole (antiplatelet effect of clopidogrel potentially reduced)6409276.611*366143.8
Paracetamol prescribed at a dose of 4 g over 24 hours to a patient under 50 kg (risk of hepatocellular toxicity)7841253.04863293.4
Selective serotonin reuptake inhibitor prescribed concomitantly with tramadol (increased risk of serotonin syndrome)81612414.917*14153.5
Potassium-sparing diuretic (excluding aldosterone antagonists) prescribed to a patient also receiving an ACE inhibitor or angiotensin-II receptor antagonist (increased risk of severe hyperkalaemia)9334236.96272228.1
Statin prescribed concomitantly with a macrolide antibiotic (increased risk of myopathy)10434204.615*40661.5
More than one paracetamol-containing product prescribed to a patient at a time (maximum dose exceeded)15*841141.77863202.3
ACE inhibitor or angiotensin-II receptor antagonist prescribed to a patient with a potassium level >5.0 mmol/L (can cause or exacerbate hyperkalaemia)11*334195.79272197.0
Soluble insulin prescribed to a patient on a when-required basis (increased risk of serious episodes of hypoglycaemia and nocturnal hypoglycaemia post dose)17*1041312.5101131614.2
  • *Errors ranked outside the top 10 for the stated period, but are included as they were inside the top 10 for the other period.

  • CPOE, computerised physician order entry; NErr, number of errors; NOpp, number of opportunities for error.