Errors considered Reportable as Adverse Incidents
Type
Scenario
1.
Prescribing or administration of any drug for the wrong patient
2.
Omitted doses, either with a blank space or where drug is not available, of a ‘critical’ drug
3.
Non-prescription of a ‘critical’ drug where it is documented in the drug history
4.
Omitted doses of non critical medicines for a period > 48hrs
5.
Non-prescription of any drug for a period of 48 hours where the drug is documented in the
drug history and a request has been made to prescribes it.
6.
Prescribing or administration of a drug where the patient has a documented allergy or
sensitivity to that drug.
7.
Prescribing of an aminoglycoside or vancomycin without adequate monitoring
8.
Amending any existing prescription rather than re-writing the prescription
9.
Prescribing of units abbreviated to u, and unclear doses in volumes rather than dose units
i.e. mls not mg.
10.
Prescribing an incorrect presentation of a drug with potential for patient harm, for example
using IV vancomycin for the treatment of C. difficile.
11.
Failure to follow Antibiotic Policy for formulary advice or length of treatment for greater
than 5 days.
12.
Prescribing a drug resulting in the incorrect preparation and harmful administration of a
dose e.g. diluents, concentration or rate
13.
Inappropriate duplicate prescribing or prescribing two drugs for the same indication with
potential for patient harm. This also applies to administration incidents. (Excluding
combination of when required paracetamol and co-codamol.)
14.
Actual or near miss dosing errors with cytotoxic or immunosuppressant drugs
15.
Inappropriate prescription or administration of any drug at the wrong dose, frequency ,
route or where there is a contraindication or interaction.
16.
Inappropriate prescribing of a drug with a narrow therapeutic index for example,
phenytoin, digoxin, gentamicin, vancomycin or lithium
17.
Any prescribing error which has resulted in actual patient harm
18.
Significant problems in contacting an appropriate prescriber resulting in delays in supplying
medication, a delayed TTO or an extended wait for outpatients
19.
Any dispensing error that leaves the pharmacy dispensary.
20.
Inappropriate, prescribing, administration, storage or transfer of Controlled Drugs
21.
Failure in cold chain storage of medicines resulting in wastage of medicines
22.
Administration of expired medicines or supply of expired medicines to wards or
departments