Table 1.
Types and Frequency of Dosage Form Prescribing Errors
| Error Description | Example | n | % | n (%) Error Types Rated Fatal/Severe or Serious (Total Fatal/Serious/Severe Errors = 52) |
|---|---|---|---|---|
| Failure to specify controlled delivery dosage form; prescribed by brand name | Cardizem 240 mg PO daily | 148 | 36.8 | 27 (51.9) |
| Failure to specify correct controlled delivery form; prescribed by generic name | Nifedipine 90 mg PO daily | 132 | 32.8 | 5 (9.6) |
| Controlled delivery formulation ordered to be given per tube | Imdur 30 mg per tube once daily | 48 | 11.9 | 0 |
| Controlled delivery formulation prescribed on an “as needed” basis | OxyContin 20 mg PO every 8 h as needed for pain | 30 | 7.5 | 0 |
| Failure to specify unique formulation with significant bioavailability differences | Cyclosporine 100 mg PO daily when cyclosporine modified microemulsion intended | 12 | 3 | 12 (23.1) |
| Inappropriate dose frequency for controlled-delivery dosage form | Fentanyl transdermal patch every 7 days | 10 | 2.5 | 0 (0) |
| Oral dose amount ordered to be given IV | Colchicine 0.5 mg IV every 6 h | 4 | 1 | 2 (3.8) |
| Failure to specify unique dosage form with significant pharmacodynamic differences | Amphotericin B 250 mg IV daily instead of amphotericin B lipid complex | 3 | 0.7 | 3 (5.8) |
| Order to crush or otherwise disrupt a controlled-release formulation | Imdur 60 mg daily; crush and sprinkle in applesauce | 2 | 0.5 | 0 |
| Order for IM administration of formulation designed to be given SC | NPH insulin 20 units IM | 2 | 0.5 | 0 |
| Order for IV administration of formulation designed to be given IM | Betamethasone 12 mg IV every 12 h | 2 | 0.5 | 2 (3.8) |
| Order for oral administration at dose used for IM formulation | Fluphenazine 50 mg PO daily | 2 | 0.5 | 0 |
| Order to give topical paste at transdermal patch frequency | Nitrogycerine paste 0.2% daily | 2 | 0.5 | 0 |
| Order to give IV dose PO | Vancomycin 1 g PO every 12 h | 1 | 0.2 | 1 (1.9) |
| IM formulation to be given SC | Testosterone enanthate SC | 1 | 0.2 | 0 |
| Order to give controlled delivery formulation sublingually | Nifedipine 30 mg SL daily | 1 | 0.2 | 0 |
| Order to give rectal dosage form orally | Mesalamine rectal suspension PO every 6 h | 1 | 0.2 | 0 |
| Wrong indication for dosage form | Divalproex for acute oral loading dose of valproic acid instead of valproiuc acid liquid | 1 | 0.2 | 0 |
| Total | 402 | 52 |
PO, by mouth; IV, intravenously; IM, intramuscularly; SC, subcutaneously; SL, sublingually.