Medication Prescribing Error Reporting and Prevention Program: A 14-Year Experience

Timothy S. Lesar, PharmD


August 14, 2000

In This Article

Summary of Collected Data

A total of 20,966 prescribing errors have been detected and documented by the program over the past 14 years (Figure 2). A detailed summary of the data for the first 9 years has been previously published.[8] The most common types of errors detected as a percent of all errors are overdoses and underdoses. The most common drug classes involved in prescribing errors are antimicrobials, cardiovascular agents, gastrointestinal agents, analgesics, and hormonal agents. Analysis of "contributing" factors[9] consistently demonstrates that, as a percentage of all errors, most common factors were deficiencies related to knowledge of drug therapy (approximately 30% of errors), failure to account for patient characteristics in making drug therapy decisions (approximately 30% of errors), calculations and "decimal points" (approximately 15% of errors), prescribing nomenclature (approximately 13% of errors), and inappropriate use or understanding of drug formulations (approximately 3% of errors).

Figure 2.

Frequency of prescribing errors detected by AMC Medication Prescribing Program 1987 to 1999.

The database provided by the described program has enabled evaluation of specific subgroups of prescribing errors involving a number of contributors[9] and medication classes. These specific areas include: dosage forms,[15] high-dose methylprednisolone for acute spinal cord injury,[16] use of dose equations,[17] low-dose methotrexate,[18] thrombolytics,[19] antibiotics,[20,21] antiretrovirals,[22] analgesics (Smith H, Tong F, Gailey R, Lesar T, unpublished data), nitrates (Lesar TS, Gailey R. Nitrate prescribing errors and problems in hospitalized patients, unpublished data), and pediatrics (Lesar TS. Factors related to prescribing errors in pediatric patients, unpublished data).


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