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Table 2 Reasons identified by interns as causes of different types of discharge prescribing errors

From: Assessment of an electronic patient record system on discharge prescribing errors in a Tertiary University Hospital

Omission of medications (n = 21) Errors relating to frequency, dose or formulary (n = 19)
Omission of medications on admission (7)
Unclear documentation of medication changes (4)
Poor handwriting (3)
Multiple medication prescription charts used (3)
Time pressure (3)
Distractions (i.e. being paged) while discharging (2)
Unfamiliar with patient (1)
Polypharmacy (1)
Poor handwriting (6)
Lack of familiarity with certain medications (4)
Time pressure (4)
Lack of familiarity with patients (2)
Failure to check guidelines/formularies (2)
Difficulty accessing admission medication list during a prolonged admission (2)
Human error (2)
Unclear documentation of medication changes (1)
Inexperience (1)
Communication error (n = 9) Prescription of a medication that was intentionally stopped during inpatient stay (n = 15)
Time pressure (3)
Unclear documentation of medication changes (2)
Unfamiliar with patient (2)
Patient knowledge of pre-admission medications (1)
Discontinuation not clearly documented (4)
Reason for discontinuation not clearly documented(3)
Unfamiliar with patient (2)
Poor admission notes (1)
Misreading medication prescription charts (1)
Use of paper charts (1)
Inaccurate note taking (1)
Medications which were held not being restarted appropriately (1)
Time pressure (1)
Are there any other types of error which you think are common on discharge? (n = 5) Are there any other aspects of discharge prescribing which you think warrant further investigation? (n = 3)
Duration of medication (3)
Errors due to patients being discharged on weekends(1)
Not documenting benzodiazepines appropriately (1)
Guidance on opiate prescribing at discharge (2)
Variability in clinicians (1)
Difficulty contacting clinicians (1)