| Admission diagnosis | Description of error | Type and clinical significance |
|---|---|---|
| Extremity fracture | Patient had drug-eluting stent placed within previous year and was taking dual antiplatelet therapy; acetylsalicylic acid was omitted from admission orders Perindopril-indapamide was ordered on admission; however, this medication had been previously stopped and patient was no longer taking it | Omission, class III Reorder error, class II |
| Upper gastrointestinal bleed | Patient's hydrochlorothiazide was reordered despite symptomatic hypotension at presentation Gliclazide was ordered on admission; however, this medication had been previously stopped and patient was no longer taking it | Inappropriate continuation, class II Reorder error, class II |
| Pneumonia, COPD | Patient's budesonide was omitted despite regular use in setting of severe COPD | Omission, class II |
| Depression | Patient's budesonide-formoterol was discontinued on admission orders despite regular use in setting of severe COPD and asthma Patient's prednisone was discontinued on admission orders despite regular use | Discontinuation, class II Discontinuation, class II |
| Syncope | Patient's hydrochlorothiazide was continued despite symptomatic orthostatic hypotension at presentation | Inappropriate continuation, class II |
| Schizophrenia | Patient's zuclopenthixol was ordered as 60 mg intramuscularly every 2 wk as per PharmaNet; however, patient was taking 40 mg intramuscularly every 2 wk | Change in dosage, class II |
| Weakness | Patient's acetylsalicylic acid was omitted from admission orders (indication transient ischemic attacks) | Omission, class II |
| Asthma | Indomethacin was ordered on admission; however, patient was no longer taking this medication | Reorder error, class II |
| Dyspnea | Patient's acetylsalicylic acid was omitted from admission orders (indication coronary artery disease) | Omission, class II |
| Fall | Patient's amlodipine was continued despite symptomatic hypotension | Inappropriate continuation, class II |
| Cancer | Celecoxib was ordered regularly as per PharmaNet; however, patient took this as needed | As needed to regular, class II |
| Pulmonary embolism | Patient's metoprolol was continued despite symptomatic hypotension Patient's perindopril was continued despite symptomatic hypotension Patient's acetylsalicylic acid was omitted from admission orders (indication coronary artery disease) | Inappropriate continuation, class II Inappropriate continuation, class II Omission, class II |
| Hypovolemia, atrial flutter | Imatinib was ordered on admission as per PharmaNet; however, patient was no longer taking this medication | Reorder error, class II |
| Transient ischemic attack | Patient was taking 7.5 mg of zopiclone at bedtime; however, it was ordered as 11.25 mg at bedtime as needed as per PharmaNet | Change in dosage, class II |
| Pneumonia, sepsis | Patient was taking dantrolene, 100 mg 4 times daily, but it was ordered as 400 mg 4 times daily as per PharmaNet | Change in dosage, class II |
| Urinary tract infection, sepsis | Patient was using fluticasone regularly for asthma but this was omitted | Omission, class II |
| Urinary tract infection | Patient was taking carbidopa-levodopa extended release 3 times daily and at bedtime as needed; however, this was ordered as once daily as per PharmaNet | Change in frequency, class II |
| Sepsis | Patient was taking methadone, 3 mg every 8 h, but this was ordered as 2 mg every 8 h as per PharmaNet | Change in dosage, class II |
| Pyelonephritis | Patient's bisoprolol was continued in setting of symptomatic hypotension | Inappropriate continuation, class II |
Note: COPD = chronic obstructive pulmonary disease.