Table 3 Forty prescription‐only medications used in different doses or regimens than prescribed in discharge letter.

Sex	Age (years)	Drug	Prescribed use	Actual use	Indication for use	Implication of incongruent use
Female	85	Nifedipine	60 mg ×1	60 mg ×2	Hypertension	Risk of hypotension
Female	76	Glimepiride	3 mg ×1	6 mg ×1	Diabetes	Risk of hypoglycaemia
Male	62	Terbutaline	7.5 mg ×1	7.5 mg ×2	COPD	Risk of side effects
Female	82	Isosorbide dinitrate	80 mg ×1	80 mg ×2	Angina pectoris	Risk of hypotension
Female	64	Citalopram	20 mg ×1	10 mg ×1	Depression	Risk of insufficient treatment
Female	58	Citalopram	90 mg ×1	60 mg ×1	Depression	Unprescribed but probably relevant dose reduction
Female	79	Levothyroxine	0.1 mg ×1 and 0.15 ×1 on alternate days	0.1 mg ×1 and 0.2 ×1 on alternate days	Hypo‐thyreoidism	Dose reduced during hospitalisation. Poorer regulation of myxoedema
Male	57	Phenobarbital	100 mg ×1	100 mg ×2	Epilepsy	Risk of side effects
Female	88	Allopurinol	100 mg ×2	100 mg ×1	Gout	Risk of insufficient treatment
Male	79	Verapamil	240 mg ×1	240 mg ×2	Heart arrhythmia	Risk of hypotension
Female	91	Nitrofurantoin	50 mg ×1	25 mg ×1	Chronic cystitis	Risk of insufficient treatment
Female	52	Omeprazole	20 mg ×2	20 mg ×3	Ulcer	Risk of side effects
Female	79	Esomeprazole	40 mg ×1	20 mg ×1	Ulcer	Risk of insufficient treatment

COPD, chronic obstructive pulmonary disease.

Other prescription‐only medication used in different doses and/or regimens than prescribed: inhalation therapy in obstructive pulmonary disease (11 patients), analgesics (6 patients), diuretics (2 patients), sedatives (6 patients), others (2 patients).