Medication error detail
| Medication name | Error | Risk | Comment | Diagnoses |
|---|---|---|---|---|
| Lactobacillus | Omission | NS | CF, haemoptysis, MRO | |
| Azithromycin | Omission | NS | M, W, F | CF, haemoptysis, MRO |
| Fluticasone | Omission | NS | Nasal spray | CF, haemoptysis, MRO |
| Inhaled 7% NaCl | Omission | NS | CF, haemoptysis, MRO | |
| Vitamin D | Omission | NS | IU | CF, haemoptysis, MRO |
| Lactobacillus | Omission | NS | CF, haemoptysis, MRO, abdominal pain | |
| Azithromycin | Omission | NS | CF, haemoptysis, MRO, abdominal pain | |
| Inhaled 7% NaCl | Omission | NS | CF, haemoptysis, MRO, abdominal pain | |
| Ofloxacin otic | Omission | NS | Should use per ENT | Spastic paraplegia, vomiting, diarrhoea |
| Ursodiol | Omission | 1 | Parent absent, patient does not know | CF, haemoptysis, MRO |
| Fluticasone/salmeterol | Omission | 1 | 100/50 | CF, haemoptysis, MRO |
| Ergocalciferol | Omission | 1 | IU | CF, haemoptysis, MRO |
| Fluticasone/salmeterol | Omission | 1 | 100/50 | CF, haemoptysis, MRO, abdominal pain |
| Ergocalciferol | Omission | 1 | CF, haemoptysis, MRO, abdominal pain | |
| Venlafaxine | Omission | 1 | Sees three MDs, gets ‘consensus’ | Crohn disease, GORD, asthma |
| Erythromycin | Omission | 1 | Short gut, sepsis, abdominal distension | |
| Aspirin | Omission | 2 | Short gut, liver transplant, sepsis, hepatitis | |
| Dornase alpha | Frequency | 1 | Every day, should be twice daily | CF, CP, DD, OSA, diarrhoea |
| Fluticasone | Frequency | 1 | Every day, should be twice daily | Spastic paraplegia, vomiting, diarrhoea |
| Trazodone | Frequency | 1 | Scheduled, should be ‘prn’ | DKA, VP shunt, panhypopit, pancreatitis |
| Lansoprazole | Frequency | 1 | Every day, in this patient should be twice daily | CHD, DiGeorge, hypocalcaemia |
| Cholestyramine | Frequency | 1 | Thrice daily, should be twice daily | Short gut, liver transplant, sepsis, hepatitis |
| Trimethoprim/sulfamethoxazole | Frequency | 1 | Every day, should be twice daily on M, W, F | Short gut, liver transplant, sepsis, hepatitis |
| Loperamide | Formulation | NS | ml, 1 mg/5 ml | Short gut, liver transplant, sepsis, hepatitis |
| Vitamin A, D, E, K | Dose, frequency | NS | 2 ml every day, should be 1.5 ml twice daily | CF, CP, DD, OSA, diarrhoea |
| CaCO3 | Dose, frequency | 1 | 175 mg six times a day, should be 150 mg five times a day | CHD, DiGeorge, hypocalcaemia |
| FeSO4 | Dose, formulation | NS | 6.25 mg–15 mg/6ml, should be 15 mg–15 mg/0.6 ml | Nephrotic syndrome, renal transplant, sepsis |
| Famotidine | Dose | NS | 10 mg, should be 13.6 mg | CF, CP, DD, OSA, diarrhoea |
| Lansoprazole | Dose | NS | 10 mg, should be 15 mg | Diabetes, asthma, pancreatitis |
| Gabapentin | Dose | NS | 25 mg, should be 37.5–100 mg | Medulloblastoma, pneumonia, seizure, sepsis |
| Calcitriol | Dose | 1 | 2.5 ml, should be 0.25 ml | CHD, DiGeorge, hypocalcaemia |
| Hydrocortisone | Dose | 3 | No stress dosing | DKA, VP shunt, panhypopit, pancreatitis |
| Hydrocortisone | Dose | 3 | No stress dosing | Panhypopit, respiratory distress, CP, DD, seizure |
| Hydrocortisone | Dose | 3 | No stress dosing | Nephrotic syndrome, renal transplant, sepsis |
| Prednisone | Dose | 3 | No stress dosing | Short gut, liver transplant, sepsis, hepatitis |
| Tacrolimus | Dose | 3 | Level low, dose decreased | Short gut, liver transplant, sepsis, hepatitis |
ADE, adverse drug event; ADE risk: NS, not significant; 1, significant; 2, serious; 3, life-threatening; 4, fatal.
CF, cystic fibrosis; CHD, congenital heart disease; CP, cerebral palsy; DD, developmental delay; DKA, diabetic ketoacidosis; GORD, gastro-oesophageal reflux disease;
MRO, multiply resistant organism; OSA, obstructive sleep apnoea; VP, ventriculoperitoneal.