Table 2

Examples of prescribing errors with or without incident reports by potential severity level

Potential severity level	Potential severity rating*	Error description	Error type†	Reported to the hospitals’ incident reporting system (yes/no)	Actual harm level if applicable
Minor	1	Ondansetron oral disintegrating tablets prescribed with sublingual route rather than oral route.	Wrong route	No
	1	Total daily dose of valproate prescribed in three divided doses when guidelines recommend two divided doses.	Wrong frequency	No
	2	Prescribed initial dose of vancomycin calculated to 2100 mg. Initial dose should be capped at 1500 mg.	Overdose	Yes
Potentially serious	3	Gentamicin once-only dose prescribed to patient using a dosing weight of 10 kg. Patient’s actual weight was 3.9 kg‡.	Overdose	Yes	Minor
	3	Ibuprofen prescribed with postsurgical intravenous ketorolac.	Duplicated drug therapy	No
	3	Patient was prescribed half the recommended treatment dose of piperacillin/tazobactam for infection‡.	Underdose	No	Moderate
	4	Insulin prescribed for a patient who does not have diabetes.	Wrong drug	No
	4	Dose of ketamine given ‘once only’ intravenously for induction/sedation was almost three times the maximum recommended dose‡.	Overdose	No	Moderate
	4	Wrong intravenous cephalosporin prescribed, leading to errors also with dose and frequency‡.	Wrong drug	Yes	Minor
	5	Midazolam continuous infusion for seizures not ceased when new order prescribed.	Duplicated drug therapy	No
	5	Intranasal fentanyl prescribed in milligrams instead of micrograms, creating 1000-fold overdose.	Overdose	No

*See online supplemental appendix S1 for the prescribing error potential harm severity rating scale.
†See online supplemental appendix S2 for prescribing error type definitions.
‡Error associated with actual harm.