Table A1.
| Patient description, age/race/sex | Drug/agent | Reaction | Contributing factor |
| Pharmacist group | |||
| 72/AA/male | Amiodarone, dose too low | Atrial fibrillation | Hypokalemia |
| 55/AA/female | Furosemide | Hypernatremia | Diabetes insipidus, secondary to lithium toxicity (upon admission), furosemide given for CHF; occurred on a Saturday |
| 51/AA/male | Furosemide | Hypokalemia | Identified on first day of ICUb; pharmacist not on schedule |
| 74/White/female | Labetolol, dose too high | Hypotension (initial BP 200/165 fell to 100/68) | Stroke patient |
| 18/H/male | Prednisone + dexamethasone | Serum glucose 254 | Insulin protocol not ordered; occurred Sunday |
| 75/AA/female | Sodium bicarbonate | Respiratory alkalosis | Plasma pH 7.57; chronic renal failure |
| 57/AA/male | Sulfamethoxazole/trimethoprim; interaction with captopril | Increased potassium acidosis |
Occurred Sunday |
| Control group | |||
| 50/W/female | Atenolol | Hypotension | Should have discontinued atenolol |
| 70/AA/male | Colchicines | Hypotension | ESRD |
| 18/AA/female | Dextrose IVF | Exacerbated condition | Diabetic ketoacidosis |
| 79/AA/female | Digoxin | AV blockade | Acute renal failure |
| 81/W/male | Furosemide | Hypokalemia | |
| 82/AA/male | Furosemide | Metabolic alkalosis, hypotension | |
| 54/AA/male | Furosemide (failed to discontinue) | Contraction alkalosis, hypotension | |
| 81/AA/female | Flumazenil (inappropriate indication) | Increased risk of seizure | CVA |
| 78/AA/male | Furosemide + prednisone | Contraction alkalosis (over diuresis) | |
| 21/AA/female | IVF with no potassium | Hypokalemia, anion gap | |
| 63/AA/female | (1) Lisinopril | (1) Hyperkalemia | Adverse drug events 2-4 occurred on Sunday; muscle weakness was due to malnutrition |
| (2) HCTZ | (2) Hypotension, metabolic alkalosis | ||
| (3) Morphine | (3) Constipation | ||
| (4) Prednisone | (4) Thrush | ||
| (5) Prednisone | (5) Muscle weakness | ||
| (6) Diazepam + lisinopril | (6) Hypotension | ||
| 55/W/male | Metoprolol | Bradycardia | Orders written without BP and heart rate parameters for holding dose; occurred Saturday |
| 47/W/male | Spironolactone | Hyperkalemia | Acute renal failure |
| 83/AA/female | Stress ulcer prophylaxis not ordered | Stress ulcer | |
Note:AA = African American; AV = atrioventricular; BP = blood pressure; CHF = congestive heart failure; CVA = cerebrovascular accident; ESRD = end-stage renal disease; H = Hispanic; HCTZ = hydrochlorothiazide; ICU = intensive care unit; IVF = intravenous fluid; W = White.