Most commonly reported prescribing error types
Drug involved | Overview of incident | Frequency N (%) | Specific error type | Frequency N (%) |
Amoxicillin | Prescribed when contraindicated due to allergy | 16 (4.8) | Prescribed in penicillin allergy | 15 (4.5) |
Prescribed in cephalosporin allergy | 1 (0.3) | |||
Co-amoxiclav | Prescribed when contraindicated due to allergy | 15 (4.5) | Prescribed in penicillin allergy | 15 (4.5) |
Insulin | Prescribed incorrect type | 11 (3.3) | Prescribed incorrect type of long acting insulin | 3 (0.9) |
Prescribed short/rapid acting insulin instead of mixed insulin | 3 (0.9) | |||
Unknown | 2 (0.6) | |||
Prescribed short/rapid acting insulin instead of long acting insulin | 1 (0.3) | |||
Prescribed incorrect type of mixed insulin | 1 (0.3) | |||
Prescribed two long-acting insulins simultaneously | 1 (0.3) | |||
Prescription omitted | 10 (3.0) | Unknown | 3 (0.9) | |
Insulin not documented in medicines reconciliation | 2 (0.6) | |||
Insulin not prescribed on transfer to rehabilitation unit | 2 (0.6) | |||
Insulin prescribed once daily instead of twice daily | 1 (0.3) | |||
No subcutaneous insulin prescribed on discontinuation of intravenous insulin | 1 (0.3) | |||
Insulin inappropriately withheld due to concerns re hypoglycaemia | 1 (0.3) | |||
Gentamicin | Prescribed incorrect dose | 7 (2.1) | Dose calculated using incorrect weight | 2 (0.6) |
Dose too high | 2 (0.6) | |||
Dose calculated using outdated blood results | 1 (0.3) | |||
Dose calculated using eGFR instead of creatinine | 1 (0.3) | |||
Dose prescribed in excess of maximum daily dose | 1 (0.3) | |||
Incorrect drug monitoring | 7 (2.1) | Level not taken post administration | 6 (1.8) | |
Level taken too early post administration | 1 (0.3) | |||
Prescribed incorrect dosage frequency | 6 (1.8) | Prescribed 24 hourly instead of 48 hourly | 2 (0.6) | |
Prescribed without checking level <1 in patient with renal impairment | 2 (0.6) | |||
Prescribed 48 hourly instead of 24 hourly | 1 (0.3) | |||
Prescribed 12 hourly instead of 24 hourly | 1 (0.3) | |||
Vancomycin | Prescribed incorrect dose | 5 (1.5) | Loading dose prescribed instead of maintenance dose | 2 (0.6) |
Dose too high | 2 (0.6) | |||
Dose too low | 1 (0.3) | |||
Paracetamol | Duplication of therapy | 5 (1.5) | Prescribed regularly and as required | 2 (0.6) |
Prescribed alongside co-codamol | 2 (0.6) | |||
Prescribed alongside co-dydramol | 1 (0.3) | |||
Enoxaparin | Prescribed without indication | 5 (1.5) | Prescribed when patient already anticoagulated | 3 (0.9) |
Prescribed for incorrect patient | 1 (0.3) | |||
Prescribed in line with outdated guidelines | 1 (0.3) | |||
Warfarin | Prescription omitted | 5 (1.5) | Unknown | 4 (1.2) |
Not prescribed on transfer to rehabilitation unit | 1 (0.3) |