Table 4

Error type for renal-specific errors, categorised by type of medication, error description, potential negative outcome and severity

Medication categoryError descriptionPotential negative outcomeSeverity
Medicines used in chronic kidney diseasePrescription for ‘Epo’. Inappropriate abbreviation used with no brand or dose specifiedPrescription is unclear and therefore nursing staff would be unable to administer the medication. As a consequence, the patient may not receive the treatment or it could lead to inappropriate delays.Severe
Calcium carbonate prescribed as a phosphate binder for a patient with hypercalcaemiaExacerbation of hypercalcaemia potentially causing lethargy, weakness, confusion, coma, constipation, nausea, anorexia and arrhythmiasSevere
AnticoagulationDalteparin (12 500 units once daily) prescribed for a deep venous thrombosis in a patient on haemodialysisLow molecular weigh heparins given at conventional treatment doses to patients on haemodialysis will accumulate, which can complicate reversal of anticoagulation.Severe
AntimicrobialsClarithromycin prescribed in combination with tacrolimus and atorvastatin (significant interactions)Increased exposure to atorvastatin and tacrolimus, which could lead to myopathy (atorvastatin) and nephrotoxicity and neurotoxicity (tacrolimus)Severe
Wrong dose of ganciclovir prescribed (500 mg tds instead of 500 mg bd)Increased exposure to ganciclovir, which could lead to neurotoxicity and myelosuppressionSevere
Incorrect (too high) dose of meropenem prescribed for a patient receiving haemodialysisIncreased exposure to meropenem which could lead to neurotoxicitySevere
Valganciclovir unintentionally omitted from a renal transplant patient medication card when it was requiredOmitting valganciclovir in these cases could result in increased risk of cytomegalovirus diseaseSevere
ImmunosuppressionTreatment with mycophenolate mofetil inadvertently continued for a renal transplant patient with cytomegalovirus infectionIf immunosuppression is not minimised, this could compromise the success of treatment for cytomegalovirus disease in renal transplant patients.Severe
New transplant patient whose medication chart did not include any immunosuppression or adjuvant agents given after renal transplantation. This patient was prescribed inappropriate medicines such as high-dose furosemide and phosphate binders (no longer indicated)Lack of prescribed immunosuppression following renal transplantation will increase the risk of acute rejection and graft loss.Severe
Prograf dose prescribed as 500 mg instead of 500 microgramsAlthough it is unlikely that the dose would have been given (100 capsules of 5 mg would have to be administered), this error constitutes a 1000-fold overdose which would almost certainly be fatal.Lethal