HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS REGISTER		Author Keyword(s) Vol Page [Advanced]

This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this link to a friend Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dean, B Articles by Schachter, M Search for Related Content PubMed PubMed Citation Articles by Dean, B Articles by Schachter, M Related Collections Changing physician behavior Quality improvement

What is a prescribing error?

B Dean, director ^*

Academic Pharmacy Unit, Hammersmith Hospitals NHS Trust, London W12 0HS

N Barber, professor of the practice of pharmacy

Centre for Practice and Policy, The School of Pharmacy, University of London, London WC1N 1AX

M Schachter, senior lecturer and honorary consultant physician

Department of Clinical Pharmacology, Imperial College School of Medicine, St Mary's Hospital, London W2 1NY

Dr B Dean bryony{at}cua.ulsop.ac.uk Objective—To develop a practitioner led definition of a prescribing error for use in quantitative studies of their incidence.

Design—Two stage Delphi technique.

Subjects—A panel of 34 UK judges, which included physicians, surgeons, pharmacists, nurses and risk managers.

Main outcome measures—The extent to which judges agreed with a general definition of a prescribing error, and the extent to which they agreed that each of 42 scenarios represented a prescribing error.

Results—Responses were obtained from 30 (88%) of 34 judges in the first Delphi round, and from 26 (87%) of 30 in the second round. The general definition of a prescribing error was accepted. The panel reached consensus that 24 of the 42 scenarios should be included as prescribing errors and that five should be excluded. In general, transcription errors, failure to communicate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not.

Conclusions—Health care professionals are in broad agreement about the types of events that should be included and excluded as prescribing errors. A general definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be included. This definition allows the comparison of prescribing error rates among different prescribing systems and different hospitals, and is suitable for use in both research and clinical governance initiatives.

(Quality in Health Care 2000;9:232–237)

Key Words: prescribing errors; medication errors; definition of error

This article has been cited by other articles:

				A. G. Kennedy, B. Littenberg, and J. W. Senders Using nurses and office staff to report prescribing errors in primary care Int. J. Qual. Health Care, May 13, 2008; (2008) mzn015v2. [Abstract] [Full Text] [PDF]

				C. Estellat, I. Colombet, S. Vautier, J. Huault-Quentel, P. Durieux, and B. Sabatier Impact of pharmacy validation in a computerized physician order entry context Int. J. Qual. Health Care, October 1, 2007; 19(5): 317 - 325. [Abstract] [Full Text] [PDF]

				B. D. Franklin, K. O'Grady, P. Donyai, A. Jacklin, and N. Barber The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after study Qual. Saf. Health Care, August 1, 2007; 16(4): 279 - 284. [Abstract] [Full Text] [PDF]

				I. D Maidment, P. Lelliott, and C. Paton Medication errors in mental healthcare: a systematic review Qual. Saf. Health Care, December 1, 2006; 15(6): 409 - 413. [Abstract] [Full Text] [PDF]

				J. Stubbs, C. Haw, and D. Taylor Prescription errors in psychiatry - a multi-centre study J Psychopharmacol, July 1, 2006; 20(4): 553 - 561. [Abstract] [PDF]

				M A Ghaleb, N Barber, B Dean Franklin, and I C K Wong What constitutes a prescribing error in paediatrics? Qual. Saf. Health Care, October 1, 2005; 14(5): 352 - 357. [Abstract] [Full Text] [PDF]

				R J Lilford, M A Mohammed, D Braunholtz, and T P Hofer The measurement of active errors: methodological issues Qual. Saf. Health Care, December 1, 2003; 12(90002): ii8 - 12. [Abstract] [Full Text] [PDF]

				C. Haw Prescribing errors in psychiatry Psychiatr. Bull., October 1, 2003; 27(10): 394 - 394. [Full Text] [PDF]

				Perinatal medicine Arch. Dis. Child., April 1, 2003; 88(90001): A17 - 21. [Full Text] [PDF]

				A. Coulter After Bristol: putting patients at the centre Qual. Saf. Health Care, June 1, 2002; 11(2): 186 - 188. [Abstract] [Full Text] [PDF]

				C. J. MORRIS, J. A. CANTRILL, C. D. HEPLER, and P. R. NOYCE Preventing drug-related morbidity--determining valid indicators Int. J. Qual. Health Care, June 1, 2002; 14(3): 183 - 198. [Abstract] [Full Text] [PDF]

				A. Coulter and N. Dunn After Bristol: putting patients at the centre * Commentary: Patient centred care: timely, but is it practical? BMJ, March 16, 2002; 324(7338): 648 - 651. [Full Text] [PDF]

				C A Vincent and A Coulter Patient safety: what about the patient? Qual. Saf. Health Care, March 1, 2002; 11(1): 76 - 80. [Abstract] [Full Text] [PDF]

				B Dean, M Schachter, C Vincent, and N Barber Prescribing errors in hospital inpatients: their incidence and clinical significance Qual. Saf. Health Care, January 12, 2002; 11(4): 340 - 344. [Abstract] [Full Text] [PDF]