Dose - Examples of non-errors.
Example Number	Error category	Medication Order	CDS Rationale	Clinical Rationale
1	Prior to admission PTA dose	lamotrigine (800 mg total daily) PTA	Patient taking more than max daily dose lamotrigine (700 mg total daily) PTA
2	Appropriate dose for indication	Propofol 140 mg given for seizure	Over set max single dose of 50 mg
3	Common off-label use	Albuterol/Ipratropium inhaler ordered 6 puffs Q4H.	Exceeds max daily dose of 12 puffs and max single dose of 3 puffs	This is commonly used off-label in this amount.
4	Approximate weight-based dose	Dalteparin 17,500 units ordered daily	Exceeds max calculated weight-based dose (16,−340 units)	This is an appropriate approximation given practical logistics of dosing (RN would be unable to give this precise amount)
5	Bedside procedure, correct dose documented:	Triamcinolone 10 mg intradermal ordered for single dose of 10 mg	Exceeds max single dose.	Only 1 mg (as recommended for single dose), thus correct dose was documented as being given by MD for procedure.
6	Inappropriate alert (not max dose)	Magnesium Gluconate 2 g PO ordered one time only.	Exceeds max single dose (1 g)	Above set max dose of 1 g but not an unsafe dose.
Dose - Examples of errors
Example Number	Error category	Medication Order	CDS Rationale	Clinical Rationale
7	Overdose by max dose	Flurazepam 30–60 mg ordered daily at bedtime prn.	Max single and max daily dose 30 mg.
8	Ordered without indication	Rifampin 600 mg IV ordered Q12H	Exceeded max daily dose of 1200 mg.	However, no apparent indication for patient to be on Rifampin.
9	Order conflicts with admin instructions	Ibuprofen 600 mg ordered Q4H prn.	exceeds max daily dose of 3200 mg if given all available doses)	Automated comments of order stated to not give more than 3200 mg; however, TDD per order is 3600 mg
10	Systems/Order set	Diltiazem 0.25 mg/kg ordered Q4H prn.	(daily dose 1.5 mg/kg exceeding max daily dose of 1.05 mg/kg)	Ordered for arrhythmia per order set but patient without history of, or ongoing, arrhythmia.
Drug-drug Interaction - Examples of non-errors
Example Number	Error category	Medication Order	CDS Rationale	Clinical Rationale
1	Selected quinolones / class Ia & III antiarrhythmics	Moxifloxacin, Amiodarone Tablet 200 mg	increased risk for QT prolongation	benefit > risk for many patients, can be safely monitored.
2	tramadol/MAOIS	Linezolid, Tramadol Tablet 25 mg	increased risk for serotonin syndrome	Requires increased monitoring
3	simvastatin / diltiazem	simvastatin (> 10 mg); lovastatin (> 20 mg) / diltiazem	increased risk of statin myopathy	frequently done in the community if risk for CVD elevated with increased monitoring.
4	anticoagulants / metronidazole; tinidazole	Warfarin 12.5 mg Tablet, Metronidazole 500 mg	increased INR	Can be monitored and dose-adjusted
5	methotrexate / sulfonamides; trimethoprim	Trimethoprim 160 mg/Sulfamethoxazole 800 mg Tablet 1 tablet, Methotrexate Tablet 10 mg	methotrexate toxicity	Patients should be monitored for pancytopenia and myelotoxicity
6	methadone oraloxycodone extended release tablet	Methadone Tablet 10 mg, Oxycodone SR Tablet 30 mg	increased CNS depression/ duplicate opiate therapy	Best practice would be to administer one long acting opiate at a time, but this may be done safely with monitoring in specific clinical settings
7	naltrexone / opioid analgesics	Naltrexone Tablet 50 mg, Morphine 1–4 mg	antagonist and agonist co-administered	frequently done in treatment of acute on chronic pain
Drug-drug Interaction - Examples of errors
Example Number	Error category	Medication Order	CDS Rationale	Clinical Rationale
8a	heparin subq / enoxaparin	Enoxaparin 120 mg, Heparin 5000 Units	duplicate anticoagulant	increased risk of bleeding with low likelihood of clinical benefit
8b	heparins-dabigatran	Dabigatran Capsule 150 mg, Heparin 5000 Units	duplicate anticoagulant	increased risk of bleeding with low likelihood of clinical benefit
9a	cgmp specific pde type-5 inhibitors / nitrates	Sildenafil Tablet 12.5 mg, Nitroglycerin Sublingual Tablet 0.4 mg	hypotension, duplicate class	SL NTG and PDE’s are OK if both are PRN and pt. is educated, but Long acting/ standing nitrates are not OK
				with PDE’s: isosorbide mononitrate, transdermal patches, isosorbide mononitrate
9b	gentamicin / tobramycin	Gentamicin, Tobramycin	duplicate class	increased risk of toxicity. Duplicate class