Application of error categories and severity ratings for the Mersey Deanery Prescribing Audit
| Modified EQUIP error category | Original EQUIP error category | Includes/excludes | Severity (EQUIP) | Severity modification |
|---|---|---|---|---|
| 1. Dosing Errors | Underdose | Minor if unable/unlikely to carry out (units); Significant if dose too low to treat the condition; Serious if patient in acute distress; Potentially Lethal if medication life saving | ||
| Overdose | Excludes overdoses caused by duplication eg, Paracetamol with co-codamol | Minor if unable/unlikely to carry out (units); Significant—low TI, ½-4 times; Serious- Low TI, 4-10 times; errors in units if chance dose could be given; Potentially Lethal if very low TI and dose 10 times normal dose, results in serum levels of drug in severe toxicity range, or has high potential to cause cardiopulmonary arrest | Minor if effect of dosing expected to be minimal | |
| Dose/rate mismatch | – | Judgement used based on Equip severity categories | ||
| 2. Writing errors | Strength/dose missing | Includes dose units missing | Minor | |
| Product/formulation not specified | – | Minor | ||
| Incorrect formulation | – | Minor unless formulation likely to have implication on treatment eg, Insulin, co-careldopa, in which case significant/serious based on potential consequence | ||
| No signature | – | Significant (governance issue) | ||
| Start date incorrect/missing | – | Minor | ||
| CD requirements incorrect/missing | – | Minor | ||
| 3. Allergy status missing/significant allergy | Significant allergy | Includes allergy status not completed, or where a drug has been prescribed despite an allergy to that drug/class | – | Significant allergy status/specific allergy missed off prescription; Serious if patient prescribed agent allergic to; Potentially lethal if patient prescribed drug which previously had severe reaction to eg, oedema |
| 4. Duration of treatment wrong/not specified | Continuation for longer than needed | Includes no stop/review date for antibiotics, steroids etc | – | Minor if continuation of the medicine or the duration represents little potential for harm; Significant if continued >3 days longer than needed for medication such as: antibiotics, oral steroids, LMWH, potassium; Serious if ongoing treatment could cause serious harm |
| Premature discontinuation | Includes drugs stopped without appropriate reducing course | – | Minor if discontinuation is unlikey to have a significant clinical impact; Significant if duration of treatment insufficient to treat condition eg, Antibiotics, or if no reducing course eg, oral steroids | |
| 5. Drug Interactions | Drug interaction | Excludes 2 items prescribed from same class eg, omeprazole with lansporazole (duplication) | Serious if drug orders could exacerbate a patient's condition eg, drug–drug interaction | Significant if manufacturer advises the combination is contraindicated, should be avoided, or advises caution; Serious if adverse events highly probable |
| Drug interaction not taken into account | As above: unable to differentiate drug interaction and drug interaction not taken into account from available data | |||
| 6. Omission of medication | Omission on admission | Significant (regular medication) | – | |
| Omission on discharge | Significant | – | ||
| Drug not prescribed but indicated | – | Minor if medication is unlikely to significantly impact patient care; Significant if medication would have significant impact on clinical course Serious if medication would alleviate a serious condition /patient is in acute distress; Potentially lethal if medication is potentially life saving | ||
| 7. Excessive/ unnecessary prescribing | Duplication | Includes a second agent prescribed which contains an ingredient already being taken; 2 drugs prescribed from the same class/with same clinical effect eg, Lansoprazole + omeprazole | Minor if duplicate therapy prescribed without potential for increased adverse events | Significant, Serious, Potentiallylethal: As for overdose when duplicated items co-administered (3) |
| Unintentional prescription of drug | Drug prescribed was not that desired. Includes prescription of a discontinued drug, excluding discontinuation due to ADR, or course is too long | – | Judgement used based on Equip severity categories | |
| 8. Clinical Safety Errors | No maximum dose | Excludes prescriptions with no frequency (administration times missing/incorrect) | Minor- order lacked specific drug, dose, strength, frequency or route information | Significant if no maximum dose stated for opioids |
| Clinical contraindication | Contraindication according to summary of product characteristics | Serious if drug orders could exacerbate a patient's condition eg, Drug-disease interaction | Significant if administration unlikely to have serious clinical consequences in the given situation | |
| Continuation after ADR | – | Judgement used based on Equip severity categories | ||
| No dosage alteration after levels out of range | – | Judgement used based on Equip severity categories | ||
| 9. Lack of clear directions for administration | Administration times incorrect/missing | No frequency/times of dosing incorrect eg, In relation to food, morning vs night | Minor | Significant if administration time would be expected to affect treatment eg, Exenatide with meals, hypnotics at night |
| Incorrect route | Minor if unlikely to be carried out/little chance of toxicity/therapeutic failure; Significant if wrong route to treat condition; Serious if potential for toxicity | – | ||
| Intravenous instructions incorrect/missing | – | Judgement used based on Equip severity categories | ||
| Route missing | Minor- order lacked specific drug, dose, strength, frequency or route information | – | ||
| Daily dose divided incorrectly | Number of dosing intervals incorrect. Excludes under/overdose | – | Minor if dosing intervals are not standard, but are unlikely to significantly affect treatment; Significant if dosing intervals are inappropriate to treat the condition; Serious if medication has narrow TI and dosing intervals may affect toxicity/efficacy eg, parenteral aminoglycosides | |
| 10. Miscellaneous | No indication | Includes PRN medications, where lack of indication on prescription could prevent administration. Excludes failure to write an indication when prescribing antibiotics | – | Minor if indication not written up for PRN medication; Significant if indication not written up for formulations which are licensed for specific conditions |
| Miscellaneous | Illegible drug details, non-standard abbreviations, patient details incorrect/missing, warfarin fixed dose prescribed | – | Judgement used based on Equip severity categories |
ADR, adverse drug reaction; CD, controlled drug; PRN- when required; TI, therapeutic index.