Table 6.

Medications associated with errors in complex tasks

Prescribing error type	Examples of errors in complex tasks	Medication type	Potential implications
Dosage	Methotrexate 10 mg instead of 7.5 mg PO weekly	Cytotoxic and immunosuppressant	Dosage is highly controlled due to toxicity
	ciprofloxacin 250 mg tablet instead of IV 200 mg	Antibiotic	Wrong dose and route; efficacy threatened
Route	ciprofloxacin 250 mg tablet instead of IV 200 mg	Antibiotic	Wrong dose and route; efficacy threatened
Administration time	Fosamax PO 70 mg once/week 0800 instead of 0600	Bisphosphonate	Administered early to avoid interference of food and other medications with absorption
Frequency	Fosamax 70 mg not specified as once weekly	Bisphosphonate	Potential for overdose
	Ural q5*, q4, q3 h instead of q8 h	Urinary alkaliniser	Maximum dose is up to 4 times daily PRN
	Endone PO 5 mg PRN max 10 mg/day prescribed as q1 min PRN up to 2 doses per day	Opioid analgesic	Not rational
Cessation error	trimethoprim not ceased	Antibiotic	Drug duplication, potential interaction when ciprofloxacin is prescribed
	ranitidine not ceased	Histamine H2-receptor antagonist	Drug duplication when omeprazole is prescribed; irrational therapy
Medical omission	ciprofloxacin not added	Antibiotic	Likely serious consequences
	Ural not added	Uurinary alkaliniser	Comfort; significant
	Endone not added	Opioid analgesic	Inadequate pain relief
	omeprazole not added	Proton pump inhibitor	Symptoms not relieved and potentially dangerous—risk of bleeding.
Date	Fosamax PO 70 mg once/week 0600 starting today rather than 1 week from today	Bisphosphonate	Possible adverse drug reactions
PRN max dose omission	Max dose for Ural not specified	Urinary alkaliniser	Maximum dose is up to 4 times daily

^*Every 5 hours.