Table 1

Most commonly reported prescribing error types

Drug involvedOverview of incidentFrequency N (%)Specific error typeFrequency N (%)
AmoxicillinPrescribed when contraindicated due to allergy16 (4.8)Prescribed in penicillin allergy15 (4.5)
Prescribed in cephalosporin allergy1 (0.3)
Co-amoxiclavPrescribed when contraindicated due to allergy15 (4.5)Prescribed in penicillin allergy15 (4.5)
InsulinPrescribed incorrect type11 (3.3)Prescribed incorrect type of long acting insulin3 (0.9)
Prescribed short/rapid acting insulin instead of mixed insulin3 (0.9)
Unknown2 (0.6)
Prescribed short/rapid acting insulin instead of long acting insulin1 (0.3)
Prescribed incorrect type of mixed insulin1 (0.3)
Prescribed two long-acting insulins simultaneously1 (0.3)
Prescription omitted10 (3.0)Unknown3 (0.9)
Insulin not documented in medicines reconciliation2 (0.6)
Insulin not prescribed on transfer to rehabilitation unit2 (0.6)
Insulin prescribed once daily instead of twice daily1 (0.3)
No subcutaneous insulin prescribed on discontinuation of intravenous insulin1 (0.3)
Insulin inappropriately withheld due to concerns re hypoglycaemia1 (0.3)
GentamicinPrescribed incorrect dose7 (2.1)Dose calculated using incorrect weight2 (0.6)
Dose too high2 (0.6)
Dose calculated using outdated blood results1 (0.3)
Dose calculated using eGFR instead of creatinine1 (0.3)
Dose prescribed in excess of maximum daily dose1 (0.3)
Incorrect drug monitoring7 (2.1)Level not taken post administration6 (1.8)
Level taken too early post administration1 (0.3)
Prescribed incorrect dosage frequency6 (1.8)Prescribed 24 hourly instead of 48 hourly2 (0.6)
Prescribed without checking level <1‚ÄČin patient with renal impairment2 (0.6)
Prescribed 48 hourly instead of 24 hourly1 (0.3)
Prescribed 12 hourly instead of 24 hourly1 (0.3)
VancomycinPrescribed incorrect dose5 (1.5)Loading dose prescribed instead of maintenance dose2 (0.6)
Dose too high2 (0.6)
Dose too low1 (0.3)
ParacetamolDuplication of therapy5 (1.5)Prescribed regularly and as required2 (0.6)
Prescribed alongside co-codamol2 (0.6)
Prescribed alongside co-dydramol1 (0.3)
EnoxaparinPrescribed without indication5 (1.5)Prescribed when patient already anticoagulated3 (0.9)
Prescribed for incorrect patient1 (0.3)
Prescribed in line with outdated guidelines1 (0.3)
WarfarinPrescription omitted5 (1.5)Unknown4 (1.2)
Not prescribed on transfer to rehabilitation unit1 (0.3)