Table 3

Examples of prescribing errors classed as ‘serious’

Type of errorOrg.WardDescriptionMean scoreIntervention made?
OmissionBMedical admissionsTinzaparin 3500 units not prescribed although clinically indicated9.4Yes
OmissionAMedical admissions onePatient uses Insulin Levemir but it was not prescribed in the hospital8.5Yes
No indicationCSurgicalMorphine 10–30 mg every 6 h prescribed at discharge. Confused patient and does not require this drug8.8Yes
No indicationAMedical admissions onePatient prescribed amitriptyline 10 mg once daily but has possible acute coronary syndrome and myocardial infarction, therefore amitriptyline is contraindicated7.0Yes
Allergic to drug prescribedCMedical admissionsFlucloxacillin 1 g four times daily prescribed to a patient allergic to penicillin9.6Not recorded
Inappropriate doseCMedical admissionsPrednisolone 1 mg once in the morning prescribed but patient's usual dose is 3 mg in the morning7.5Yes
Inappropriate doseCSurgicalMorphine 15–20 mg orally ‘when required’ prescribed but no maximum dose or minimum interval stated7.4Yes
Inappropriate doseASurgicalOxycodone (as ‘Oxynorm’) prescribed twice on ‘when required’ section of drug chart: 35 mg and 40 mg, both prescribed for every 4 h. Correct dose should have been 40 mg every 4 h when required8.4Yes
Inappropriate frequency or dosing scheduleAMedical admissions twoGliclazide 80 mg prescribed at 06:00, 14:00 and 20:00. Should be at 08:00, 12:00 and 18:00, that is, with meals7.3No
Incorrect formulationBMedical admissionsIsosorbide mononitrate 120 mg once daily prescribed. Should be the modified-release form7.6Yes