1.

Develop a listing of examples where patients misunderstand the intent of the administration of a
pharmaceutical

dosage form.

For example, a prescribing error which occurs at the time a prescriber orders a drug for a specific
patient. Errors can include the selection of an incorrect drug, dose, dosage form, route of
administration, length of therapy, or number of doses. Inappropriate rate of administration, inaccurate
medication concentration, and inadequate or erroneous directions for use are all examples of
prescribing errors. Consider patient variables such as allergies, weight, age, medical indication (disease
being treated), and concurrent drug therapy, among other things, when determining if a prescription
was administered in error. A prescription for amoxicillin 250 mg PO TID, for example, may be adequate
for a five-year-old child with a middle ear infection, but the dose would be too high for a twelve-month-
old infant, and so would be deemed a prescribing error. Prescribing errors include prescriptions that are
completed erroneously due to illegible handwriting which can lead the patient to misunderstood the
order.

The abbreviation of medical terms and drug names can lead to medication errors. For example, the use
of the abbreviation "AZT" for zidovudine (Retrovir), an antiretroviral agent used to treat HIV infection,
could also be interpreted as azathioprine (Imuran), an immunosuppressant agent, which would cause
harm to the patient if an error was made. Another example of an abbreviation error is the use of "U" as
an abbreviation for units. This abbreviation could result in a tenfold error if the "U" were read as a
"zero" (e.g., 10 U insulin could be read as 100 insulin). A daily order written as "QD" instead of "daily"
may be troublesome because it could be read as "QID" (four times a day) or "OD" (every other day).

2. Develop a listing of examples where patients misuse/abuse a pharmaceutical dosage form.

According to reports, mathematical calculations errors are the cause of many drug problems. Dose
errors can cause major injury or even death to patients. Prescribers, pharmacists verifying doses for
appropriateness or calculating doses, technicians compounding medications, and nurses preparing or
administering doses all make calculation errors. Even with the use of calculators and computers, health
care personnel frequently make calculation errors.
Decimal point errors can occur as a result of a miscalculation, as described above, and also when writing
orders or instructions. Failure to write a leading zero in front of a number less than one (e.g., .1 mg
instead of 0.1 mg) can result in the number being read as a whole number (1 mg). Writing unnecessary
trailing zeros can also be confusing (e.g., 10.0 mg instead of 10 mg, which could be misinterpreted as
100 mg).