Table 1.

Nature of the error

	Problems in community pharmacies N (%)	Problems in hospitals N (%)	Examples of incidents in community pharmacies and hospitals
Data entry and record manipulation
No input
Not done*
Not done by human*	9 (2.5)	85 (25.1)	▸The pharmacist received an e-mail with a prescription; due to an unknown reason the pharmacist assistant did not enter the prescription into the system. (CP) ▸After the ward round the physician forgot to enter the prescriptions into the CPOE. (H) ▸The physician was not familiar with CPOE and could not order the medicine with the CPOE. (H)
Not possible to import record†	–	8 (2.4)	▸Rifampicin was not listed in the CPOE. The consequence was that the physician could not order rifampicin in the CPOE. (H)
Not possible to change predefined record†	–	2 (0.6)	▸The physician could not change the infusion rate of a predefined antibiotic order in the CPOE. (H)
Wrong input*
Wrong medicine†
Wrong identity medicine†	49 (13.4)	12 (3.6)	▸The pharmacist assistant entered ‘CHLOO25’ in the system and accidentally chose chlortalidone 25 mg instead of chlordiazepoxide 25 mg on the screen. (CP)
Wrong dosage form†	26 (7.1)	6 (1.8)	▸An erroneous exchange between immediate release tablet and slow release tablet. The pharmacist assistant chose the wrong medicine from the list, which was presented by the pharmacy information system. (CP)
Wrong route of administration†	1 (0.3)	1 (0.3)	▸For eye drops the right eye was entered in the pharmacy information system instead of the left eye. (CP)
Wrong strength of product†	72 (19.7)	17 (5.0)	▸The pharmacy dispensed sifrol 3.75 mg instead of 0.375 mg. (CP)
Selected medicine not available†	2 (0.5)	–	▸The general practitioners repeated a prescription and the original identification record was canceled. In the community pharmacy this repeat record cannot be recognized by the pharmacy information system. (CP)
Wrong patient†	54 (14.8)	18 (5.3)	▸Pharmacist assistant used date of birth to find a patient in the system. After entering the date of birth a list of patient names with the same day of birth was shown on the screen. A wrong patient was selected due to a poor design of screens. (CP) ▸At the ward there were two patients with the same family name. The physician selected the wrong patient on the screen of the CPOE and entered a prescription for the wrong patient. (H) ▸The physician entered a prescription into CPOE for a one-day-old newborn. During dispensing the pharmacist assistant noticed the birth day and called the ward. During the call they discovered the medicine should have been prescribed to the mother. (H)
Wrong dose/frequency†	47 (12.9)	23 (6.8)	▸A pharmacist duplicated a record in the system and accidentally repeated an outdated dose in this process. (CP)
Wrong duration of therapy/quantity of the medicine†	13 (3.6)	3 (0.9)	▸The pharmacist assistant entered 10 tablets of ondansetron 8 mg instead of 30 tablets of ondansetron. (CP)
Wrong time of administration†	2 (0.5)	23 (6.8)	▸A wrong time of administration was entered into the CPOE. The patient needed the medicine around 12 : 00 h and the time of administration in the CPOE was 14 : 00 h. (H)
Wrong infusion pump rate†	–	21 (6.2)	▸The rate of an infusion pump was accidentally set wrongly. Due to the low infusion pump rate the patient received only half of the dose. (H)
Wrong prescriber†	5 (1.4)	1 (0.3)	▸The pharmacist assistant entered the wrong code of the prescriber into the pharmacy information system. (CP)
Duplicate input†	8 (2.2)	10 (3.0)	▸The pharmacist assistant entered the prescription two times in the pharmacy information system. (CP) ▸The physician entered the same medicine twice into the CPOE. (H)
Other wrong input†	6 (1.6)	12 (3.6)	▸The physician entered diclofenac into the CPOE for a patient for whom diclofenac was contraindicated. (H)
Failure to communicate after input*	–	5 (1.5)	▸The physician entered the medication order into the CPOE but he forgot to brief the nurses about the new medication. (H)
Data retrieval
No output
System slow/down*	–	14 (4.1)	▸Physicians and nurses could not reach the CPOE because there was a large-scale IT malfunction. (H) ▸The nurse did not administer the antibiotic because the printer was down and she could not print out the administration list. (H)
Not done by human (did not look)*	14 (3.8)	11 (3.3)	▸The pharmacist assistant did not look into the notes of the patient file and missed the information that the patient needed a home delivery of the medicine. (CP) ▸Nurses did not realize the physician had entered a note in the electronic patient file and thereby missed the administration of an antibiotic. (H)
Not alerted/no output*	9 (2.5)	7 (2.1)	▸A cardiologist accidentally prescribed a high dose of flecainide for a patient in primary care and the pharmacy computer system did not alert the community pharmacist about it. There was no alert because formally it was not an overdose, but according to the cardiologist the dose was too high for the patient in primary care. There should have been an alert. (CP)
Wrong output
Output error*	5 (1.4)	9 (2.7)	▸The infusion pump alerted the nurses too late about an obstruction in the tube. (H)
Unclear output
Different output online and printed†	1 (0.3)	2 (0.6)	▸In the CPOE the nurse read that the aspirin needed to be administered with a high loading dose, but on the paper medication list the information about the high loading dose was missing. (H)
Differences between two files†	–	3 (0.9)	▸In the CPOE the nurse read from the medication list that the patient needed tolbutamid. In a separate memo field in the CPOE the nurse read that tolbutamid should not be administered to the patient. (H)
Other unclear output†	6 (1.6)	35 (10.4)	▸A community pharmacist printed out a medication list for a patient going to hospital. The printout was unclear and the consequence was that a physician in the hospital misinterpreted this medication list. He thought the patient only used 50 mg losartan per day instead of 2 times 50 mg. (CP) ▸A nurse administered 5 times more bisoprolol than prescribed. On the medication list she read that the patient needed bisoprolol and on the list the number 5 was printed without unit (mg or tablet). Eventually she administered 5 tablets of isoprolol 5 mg to the patient. (H) ▸The nurse missed a new prescription order because the printer had printed out all the orders at once with the new prescriptions at the bottom of the pile of paper (even after orders that had already been stopped). (H)
Failure to react on signal†	29 (7.4)	5 (1.5)	▸Due to alert fatigue a pharmacist assistant overruled the signal from the pharmacy barcode scanning system that the wrong medicine had been chosen. (CP) ▸The general practitioner ignored a drug–drug interaction signal. (CP) ▸The infusion pump made an alarm sound. The nurse could not identify the problem and eventually switched off the alarm of the infusion pump. (H) ▸A pharmacist assistant did not respond correctly to alerts of the pharmaceutical clinical decision support system, such as allergy warnings or drug–drug interaction warnings. For example, an order for a cephalosporin was executed despite an alert for an allergy. (H)
Other output†	2 (0.5)	1 (0.3)	▸For dispensing the pharmacist assistant printed out a list, which was not up to date anymore. (H)
Data transfer
Mistranslation of data between 2 systems†	4 (1.1)	–	▸An incomplete transfer of an e-prescription between the computers of the general practitioner and the community pharmacist. The information of the brand of the medicine was missing. (CP)
No data transfer between 2 systems†	3 (0.8)	4 (1.2)	▸A physician could not use the CPOE because of a technical malfunction in the connection between the CPOE and the medical record system in the hospital. (H)

*This preferred term was also available in the Magrabi classification.

†This preferred term is new.

CP, community pharmacies; CPOE, computerized physician order entry; H, hospitals.