01Principles and purposeThe professional or clinical skill and the decisions it supports.
Chart review is a search for mismatches between what the patient needs and what the prescribing system will deliver. Some mismatches are visible within one line, such as a weekly medicine ordered daily. Others emerge only when several lines are considered together: duplicate active ingredients, interacting treatment or an unnecessary combination that has continued after its intended end date. A third group becomes apparent only when the chart is compared with the patient’s current condition, including kidney injury, hypotension, swallowing difficulty or an untreated indication. An effective review therefore moves between the medicine list, administration record, clinical data and the treatment plan rather than reading the chart as an isolated document.
Prioritisation is part of the skill. A missing review date deserves correction, but a dose due now that could cause immediate harm takes precedence. Describe whether the hazard is possible, likely or already realised, and distinguish the uncertainty that needs clarification from the action that cannot wait. A clinician can stop an unsafe pending administration while obtaining the information needed for a replacement plan. Conversely, stopping several essential medicines because the chart is confusing can create new harm. The aim is a safe, coherent regimen with explicit ownership of unresolved questions, not the largest possible list of minor discrepancies.
Key points
- Review the patient and the whole regimen together. An individually familiar prescription can become unsafe through duplication, interaction, organ deterioration or an incorrect treatment phase.
- Start with immediate hazards: wrong patient, severe allergy, dangerous dose or frequency, duplicate high-risk treatment, omitted essential medicine and an abnormal result that changes the next dose.
- Check actual administrations separately from orders. A potential error intercepted before a dose and an error that has already reached the patient require different clinical responses.
- Add exposure by active ingredient across regular, as-needed, combination and different-route prescriptions; brand names can hide duplication.
- Compare each medicine with its indication, dose, route, formulation, frequency, duration and monitoring. A technically complete line can still have no current reason to continue.
- Document the exact problem, consequence and action. A note saying chart checked is less useful than naming the corrected order, the doses affected and the follow-up required.
- After correction, verify that the obsolete order cannot still be administered and that the intended replacement is available. Error detection is unfinished until the patient’s treatment changes safely.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Inspect units, decimal placement, route, formulation and frequency, then compare them with the indication. Daily versus weekly dosing is a particularly consequential distinction for low-dose methotrexate. An order that looks plausible at a glance may reflect selection of the wrong frequency from a menu rather than a deliberate clinical decision.
Look for duplicate active ingredients, drugs from the same class without a reason, interacting combinations and overlapping treatment phases. Check as-needed sections and supplementary charts rather than assuming the main regular list contains all exposure. A combination analgesic may add both opioid and paracetamol even when only one component was intended.
Review blood pressure, heart rate, organ function, intake and new adverse effects. A dose appropriate on admission may become unsuitable after dehydration or acute kidney injury. The relevant error may be failure to reassess a once-correct regimen, which cannot be detected by comparing the dose only with a generic reference interval.
Ask which essential long-term medicines are absent and whether the omission is deliberate. Check treatment started by ambulance staff or another ward, loading phases, temporary holds and restart plans. A missing medicine is not always an error, but the chart should make the reason clear enough that the next team does not inadvertently reverse the decision.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Medication reconciliation using reliable information - Why
- Establish the intended regimen against which the chart is reviewed.
- Interpretation and limitations
- Use the patient’s account alongside appropriate records, dispensing information or a carer where relevant. Resolve conflicting sources by investigating the most recent actual treatment decision. A historic repeat list may be accurate about long-term treatment but unaware of a specialist change made during the current admission.
- 02
Administration times and cumulative totals - Why
- Determine whether an error has reached the patient and quantify exposure.
- Interpretation and limitations
- Count doses actually given over the clinically relevant period, including different routes and combination products. Do not confuse the maximum permitted by the chart with the amount already administered. If excess exposure occurred, document exact times and quantities to support urgent clinical or toxicology assessment.
- 03
Current clinical observations and laboratory results - Why
- Identify patient-specific contraindications and monitoring failures.
- Interpretation and limitations
- Use results recent enough to describe the present situation. A normal potassium from last month cannot settle a new potassium-raising combination during acute illness. Confirm abnormal or unexpected values as clinically appropriate while acting promptly when the patient or the next dose may be at risk.
- 04
Indication-specific medicine guidance - Why
- Verify the error and identify a justified corrective regimen.
- Interpretation and limitations
- Check that the reference matches the diagnosis, treatment phase and route. An unusual dose can be an intentional specialist plan, so seek the documented rationale before labelling it wrong. If the rationale is absent and the potential harm is serious, escalate the uncertainty rather than silently accepting the order.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked exampleDetect duplicate paracetamol before administrationA 72-year-old weighing 70 kg has normal liver and kidney function. The chart contains paracetamol 1 g orally four times daily and newly added co-codamol 30/500 mg, two tablets orally up to four times daily for breakthrough pain. The administration record confirms only 2 g plain paracetamol in the last 24 hours and no co-codamol yet.+
- 1Identify the shared active ingredient: each co-codamol tablet contains 500 mg paracetamol. The breakthrough order therefore permits 2 × 500 mg = 1,000 mg paracetamol per dose, in addition to the separate regular prescription.
- 2Calculate potential exposure if both orders are fully used: regular treatment supplies 1 g × 4 = 4 g daily; the combination adds 1 g × 4 = 4 g daily. The total possible 8 g in 24 hours exceeds the ordinary 4 g adult maximum for this supplied patient.
- 3Separate potential from actual exposure. Only 2 g has been administered, so the immediate task is to prevent duplicate dosing and reassess analgesia, not to claim that an 8 g overdose has already happened. Withhold the unsafe additional administration and obtain a corrected coherent analgesic plan.
- 4Give the final action: remove or replace the duplicate-containing order through the prescribing system, retaining a clear total paracetamol limit and appropriate pain review. Independently re-add every remaining paracetamol source, confirm the obsolete order is inactive and tell the administering team which prescription now applies.
02High-risk discrepancyResolve an apparently incorrect methotrexate frequencyA chart lists oral low-dose methotrexate daily while a previous rheumatology plan specifies weekly use.+
- 1Prevent the next potentially incorrect dose while confirming the indication, usual weekly day, exact dose, formulation and recent administration history. Low-dose treatment for inflammatory disease must not be confused with a specialist oncology regimen.
- 2Check whether extra daily doses have already been taken or administered. If they have, arrange urgent clinical and specialist assessment for toxicity rather than treating the problem only as a typographical correction; obtain the quantities and dates needed for that assessment.
- 3Correct the prescription to the verified regimen with the weekly day written explicitly, and review the folic-acid schedule, supply and monitoring plan. Do not infer the patient’s dose from a standard starting dose if an established specialist regimen exists.
- 4Confirm the revised chart, pharmacy label and patient understanding agree. Record the incident and the contributing system issue so that the same frequency error is not recreated during discharge or the next admission.
03Whole-regimen reviewPrioritise interacting or unnecessary treatmentSeveral possible prescribing problems are found during a routine chart review.+
- 1Rank the findings by immediacy and severity: identify which affects a dose due now, active bleeding, dangerous electrolytes or an essential omission. Address that problem first while keeping a visible list of the remaining concerns.
- 2For each interaction, state the likely consequence and assess the patient’s actual risk. Determine whether avoidance, substitution, dose adjustment or planned monitoring is appropriate; an interaction alert alone does not specify the best clinical response.
- 3Review medicines without a current indication, expired courses and specialist combinations lacking a duration. Obtain the original rationale when possible and make a deliberate continuation or withdrawal decision rather than deleting unfamiliar treatment by default.
- 4Close each finding with a corrected order, a named reviewing clinician or a time-limited plan to obtain missing information. Recheck the chart after changes, because correction of one medicine can alter the safety or availability of another.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- When an error has reached the patient, follow the relevant clinical monitoring and treatment pathway even after the chart is corrected. The absence of immediate symptoms does not exclude delayed harm from some medicines or excessive cumulative doses.
- Check that discontinued orders are inactive on every applicable chart and that replacement orders do not create another overlap. Different electronic modules or paper supplementary charts may preserve the old instruction unless specifically reconciled.
- Revisit outstanding discrepancies at handover with an explicit owner and deadline. A note to clarify with pharmacy tomorrow is incomplete if the questionable dose is due overnight and no interim plan has been made.
- Use incident reporting and team feedback to identify recurring causes, such as default frequencies or unclear transfer records. The purpose is to improve the prescribing process while ensuring the affected patient receives immediate, appropriate care.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Potential and administered dose differ
The maximum authorised exposure describes what the chart permits, while the administration record describes what occurred. Both matter: one guides prevention, the other determines whether clinical assessment for toxicity is already needed.
A familiar medicine can conceal an error
Repeated exposure to common names can make reviewers skim the dose and frequency. Deliberately read those fields for high-risk medicines, especially where a small formatting choice changes weekly treatment into daily administration. Compare the scheduled administration days with the verified treatment calendar, because an apparently correct dose may still be due on the wrong date after a transfer.
An omission may be intentional
A medicine missing after surgery may have been appropriately held, but the reason and restart plan should be recoverable. Investigate before restoring it, particularly when bleeding, renal injury or another new contraindication was present.
Corrective action needs a second look
A revised order can accidentally duplicate the old one or remove necessary treatment entirely. The final verification should examine the resulting active regimen, not merely confirm that an edit was entered.
07Common pitfallsFrequent interpretation and management errors.
- 01
Counting branded analgesic products without checking their ingredients can miss a clinically important duplicate paracetamol exposure.
- 02
Correcting a prescription silently after excess doses have already been given can leave the patient without necessary toxicity assessment and monitoring.
- 03
Stopping an unfamiliar specialist medicine without clarifying its indication can create harm while appearing to simplify the chart.
- 04
Recording multiple low-priority formatting concerns while an unsafe dose is about to be administered fails to prioritise the immediate clinical risk.