Table 4.
Types and examples of discrepancies
| Types of Discrepancies | N | % | examples of discrepancies |
|---|---|---|---|
| Intolerance | 131 | 25.7 | NSAIDs (ibuprofen, celecoxib, et al.) prescribed for patients with severe renal impairment; aspirin (or clopidogrel) prescribed before surgery; continued use of antihypertensives should not be ordered (reserpine) before surgery; anticoagulants prescribed for patients with extensive ecchymosis after surgery |
| Omission | 112 | 22.1 | Metformin for type II diabetic patients; sedatives for patients with delirium after surgery; medication for hypertension after surgery; prophylactic antibiotics before surgery; mono-drug therapy for uncontrolled pain; omission of antifungals for infection by fungus; omission of perioperative glucocorticoids in patients with adrenocortical hypofunction (caused by long term irrational use of glucocorticoids) |
| Prolonged duration of therapy | 70 | 13.8 | Prolonged use of prophylactic antibiotics /Analgesics/Anti-Emetics/iron saccharate |
| Discrepancy in drug dose/ route/ frequency | 66 | 13.0 | Continued use of current vancomycin dose/frequency with trough drug concentration outside therapeutic range; once daily LMWH for patients with deep vein thrombosis; once/twice daily cephalosporins or piperacillin tazobactam; levofloxacin 200 mg once daily |
| Drug duplication | 61 | 12.1 | Rivaroxaban, aspirin and low molecular heparin were used as a combination for patients with deep vein thrombosis and coronary heart disease; Flurbiprofen(Patient controlled analgesia)and parecoxib(IV push)were prescribed after surgery |
| Commission | 35 | 6.9 | Moxifloxacin prescribed for urinary tract infection; Cefuroxime prescribed for infection of methicillin-resistant Staphylococcus aureus |
| Drug Interaction | 25 | 4.9 | Rivaroxaban prescribed with voriconazole(or rifampin) |
| Uncategorized | 8 | 1.6 | Patients had been using painkillers bought from Thailand which contained 5 mg of dexamethasone per pill. As pharmacist obtained this information from patients, serum cortisol level was checked upon pharmacist' advice and adrenocortical hypofunction was later diagnosed with this patient. Intravenous corticosteroid was then prescribed perioperatively |
| Total | 506 | 100 |