Synopsis
Review a medication chart systematically, identify clinically important prescribing errors and omissions, and translate findings into prioritised corrective action.
- 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.
Reasoning priorities
Establish the intended regimen against which the chart is reviewed.
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.
Worked reasoning
A 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.
- Identify 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.
- Calculate 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.
- Separate 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.
- Give 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.
Several possible prescribing problems are found during a routine chart review.