Table 2.

Examples of Potential Harm Ratings^a for Prescription Medication Order Errors

Potential harm rating	Examples of prescription medication order errors
No potential harm (NCC MERP category C)	Example 1. Simvastatin 10 mg omitted from physician’s history and admission orders
	Example 2. Escitalopram 5 mg daily recorded in physician’s history and admission orders. Patient’s community pharmacy verified dose as 10 mg
	Example 3. Sucralfate 1,000 mg four times daily ordered at admission. Pharmacist verified patient no longer taking
Potential for increased monitoring or intervention to preclude harm (NCC MERP category D)	Example 1. Baclofen 10 mg every morning and 20 mg every evening recorded in physician’s history. Order omitted despite hospital progress notes to continue
	Example 2. Lisinopril 20 mg daily recorded in physician’s history and admission orders. Verification with patient and outpatient physician’s records noted frequency was twice daily
	Example 3. Glipizide XL 2.5 mg daily recorded in physician’s history and admission orders. Verification with patient and outpatient physician’s records noted medication was glyburide 2.5 mg daily
Potential harm (NCC MERP category E-F)	Example 1. Warfarin 5 mg daily at bedtime recorded in physician’s history and admission orders. Verification with patient and spouse noted dose recently decreased to 4 mg daily at bedtime. (Admission INR 3.2. Ciprofloxacin also ordered as continuation of outpatient therapy)
	Example 2. Tacrolimus 2 mg twice daily recorded in physician’s history and admission orders. Verification with patient and outpatient physician’s records noted tacrolimus 0.5 mg daily
	Example 3. Patient with history of Addison’s disease. Physician’s history listing hydrocortisone 20 mg every morning and 10 mg every evening verified by pharmacist. Prednisone 40 mg every morning and 20 mg every evening ordered instead
	Example 4. Digoxin 125 mcg every other day recorded in physician’s history for a hemodialysis patient. Digoxin ordered daily. Pharmacist verified patient’s dose was digoxin 125 mcg three times per week

^aAdapted from the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) (www.nccmerp.org)