Table 1.

Sample prescription errors

Erroneous prescription	Error category	Resolution
IV morphine rate changed from 0.015 to 0.1 mg/kg/h	Units	Overdose based on formulary. MD changed dose to 0.01 mg/kg/h
IV midazolam rate change from 0.1 to 0.9 mg/kg/h	Units	MD intended rate change to 0.09 mg/kg/h
Rotavirus live vaccine 2 ml IM ×1	Route	MD changed order to PO route
IV hydromorphone 0.06 mg/kg/h	Formulary	Overdose based on formulary. Dose corrected to 0.006 mg/kg/h
IV cefotaxime 250 mg every 12 h	Monitoring	Dosing decreased to 125 mg due to declining renal function
Hepatitis B vaccine IM ×1	Duplicate therapy	Patient previously received vaccine. Order discontinued

Sample errors taken from feedback emails over the course of the program.

h, hour; IM, intramuscular; IV, intravenous; kg, kilogram; MD, doctorate of medicine; mg, milligram; ml, milliliter.