TABLE 4.
Types of identified prescribing errors
| Type of PE | Preintervention (464) (%) | Postintervention (366) (%) | Case(s) |
|---|---|---|---|
| No, unknown or incorrect indication | 72 (15.5) | 73 (19.9) | ‐ use of a proton‐pump inhibitor in prophylactic dose without indication. |
| ‐ nitrazepam use in a patient with a high risk of falling and fractures. | |||
| Nonadherence to guidelines | 18 (3.9) | 4 (1.1) | Initiation of a prophylactic proton‐pump inhibitor as monotherapy when not indicated. |
| Incorrect dosing | 99 (21.3) | 76 (20.8) | |
| Under‐ or overdosing | 54 (11.6) | 57 (15.6) | |
| No maximum dose if prescribed as needed | 37 (8.0) | 0 (0) | |
| Incorrect dosing frequency | 8 (0.9) | 19 (1.9) | |
| Incorrect or no dosing unit registered | 3 (0.6) | 0 (0) | ‐ sodium phosphate enema dosed as 1 mL instead of 1 piece. |
| ‐ paracetamol 4 times daily 1 instead of 4 times daily 1 g. | |||
| Incorrect duration of medication therapy | 3 (0.6) | 11 (3.0) | |
| Inadequate instructions for medication use or administration | 221 (47.6) | 168 (45.9) | |
| Incorrect route of administration | 4 (0.9) | 19 (5.2) | Paracetamol administered intravenously while patient was taking other medication orally. |
| Incorrect registration of administration route | 165 (35.6) | 113 (36.3) | Registered as per os while medication administered over nasogastric tube. |
| No or incorrect instructions for use | 44 (9.5) | 34 (9.3) | |
| Incorrectly registered administration time | 8 (1.7) | 2 (0.5) | |
| Incorrect medication form | 4 (0.9) | 4 (1.1) | Metoprolol succinate instead of tartrate. |
| (pseudo) medication duplication | 23 (5.0) | 14 (3.8) | ‐ simultaneous use of diazepam and temazepam for insomnia as lower back pain. |
| ‐ psyllium fibres and simultaneous use of macrogol with electrolytes (movicolon) for obstipation, while the guidelines state that the psyllium fibres need to be stopped as obstipation occurs during use and another laxative is indicated. | |||
| Surveillance | 45 (9.7) | 24 (6.6) | |
| Inadequate nonadherence to guidelines without registered explanation in electronic patient record | 18 (3.9) | 4 (1.1) | |
| Inadequate or no action based on clinical decision support system or computerized physician order entry alert | 4 (0.9) | 6 (1.6) | |
| No follow‐up on medication therapy | 15 (3.2) | 5 (1.4) | |
| Inadequate action for relevant contraindication | 5 (1.1) | 4 (1.1) |