Recommendation | Description and clinical consequence |
---|---|
Change drug order according to laboratory test/organ function | Ganciclovir intravenous dosage 5 mg/kg/48 hours too high. Recommended dosage according to renal function was 1.3 mg/kg/48 hours |
 | Consequence: renal failure and thus temporary harm to the patient that required prolonged hospitalization (Category F) |
Change route of administration | Azathioprine in oral form was causing abdominal pain. This adverse reaction was not recognized in a timely manner. After switching to intravenous form the abdominal pain disappeared. Consequence: temporary harm to the patient that required intervention (Category E, moderate harm to a patient) |
Change dosage | Phenytoin intravenous treatment was initiated with only a maintenance dose and without a loading dose. |
 | Consequence: an intervention was required to preclude harm to a patient (Category D). |
Change drug because of drug-disease interaction | Patient with known liver function insufficiency was started on voriconazole (antifungal medication that is mostly metabolized by the liver). |
 | Consequence: an intervention was required to preclude harm to a patient (Category D) |
Start drug | Unintended discontinuation of low-dose aspirin (patient's home medication) for 1 day |
 | Consequence: no harm to a patient (Category C) |
Change dosage | Esketamine (anesthetic) 35 mg/hour (should have been 35 μg/hour) was ordered. This medication order was intercepted in the hospital pharmacy |
 | Consequence: no harm to a patient (Category B) |
Start drug | The pharmacist proposed continuation of a statin during ICU admission. No consensus was reached with ICU physicians because of lack of evidence and the possible negative effects of the pleiotropic effect of statins. No error |