Top 10 errors occurring pre-CPOE and post-CPOE implementation across all sites
| Prescribing error | Pre-CPOE | Post-CPOE | ||||||
| Rank | NOpp | NErr | Error rate (%) | Rank | NOpp | NErr | Error rate (%) | |
| Regular opiates prescribed without concurrent use of laxatives (risk of severe constipation) | 1 | 486 | 55 | 11.3 | 3 | 438 | 37 | 8.4 |
| Benzodiazepines prescribed long term (ie, more than 2–4 weeks) (risk of dependence and withdrawal reactions) | 2 | 129 | 40 | 31.0 | 2 | 122 | 38 | 31.1 |
| Digoxin prescribed concomitantly with a diuretic (risk of hypokalaemia and subsequent digoxin toxicity) | 3 | 76 | 39 | 51.3 | 5 | 59 | 25 | 42.4 |
| 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) | 4 | 104 | 28 | 26.9 | 1 | 113 | 50 | 44.2 |
| Citalopram prescribed concomitantly with other QT-prolonging drugs (increased risk of arrhythmias) | 5 | 161 | 28 | 17.4 | 8 | 141 | 19 | 13.5 |
| Clopidogrel prescribed to a patient concomitantly with omeprazole or esomeprazole (antiplatelet effect of clopidogrel potentially reduced) | 6 | 409 | 27 | 6.6 | 11* | 366 | 14 | 3.8 |
| Paracetamol prescribed at a dose of 4 g over 24 hours to a patient under 50 kg (risk of hepatocellular toxicity) | 7 | 841 | 25 | 3.0 | 4 | 863 | 29 | 3.4 |
| Selective serotonin reuptake inhibitor prescribed concomitantly with tramadol (increased risk of serotonin syndrome) | 8 | 161 | 24 | 14.9 | 17* | 141 | 5 | 3.5 |
| 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) | 9 | 334 | 23 | 6.9 | 6 | 272 | 22 | 8.1 |
| Statin prescribed concomitantly with a macrolide antibiotic (increased risk of myopathy) | 10 | 434 | 20 | 4.6 | 15* | 406 | 6 | 1.5 |
| More than one paracetamol-containing product prescribed to a patient at a time (maximum dose exceeded) | 15* | 841 | 14 | 1.7 | 7 | 863 | 20 | 2.3 |
| 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* | 334 | 19 | 5.7 | 9 | 272 | 19 | 7.0 |
| Soluble insulin prescribed to a patient on a when-required basis (increased risk of serious episodes of hypoglycaemia and nocturnal hypoglycaemia post dose) | 17* | 104 | 13 | 12.5 | 10 | 113 | 16 | 14.2 |
*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.