What is a prescribing error?

Objective-To develop a practitioner led definition of a prescribing error f or use in quantitative studies of their incidence. Design-Two stage Delphi technique. Subjects-A panel of 34 UK judges, which included physicians, surgeons, phar macists, nurses and risk managers. Main outcome measures - The extent to which judges agreed with a general de finition of a prescribing error, and the extent to which they agreed that e ach of 42 scenarios represented a prescribing error. Results-Responses were obtained from 30 (88%) of 34 judges in the first Del phi round, and from 26 (87%) of 30 in the second round. The general definit ion of a prescribing error was accepted. The panel reached consensus that 2 4 of the 42 scenarios should be included as prescribing errors and that fiv e should be excluded. In general, transcription errors, failure to communic ate essential information, and the use of drugs or doses inappropriate for the individual patient were considered prescribing errors; deviations from policies or guidelines were not. Conclusions-Health care professionals are in broad agreement about the type s of events that should be included and excluded as prescribing errors. A g eneral definition of a prescribing error has been developed, together with more detailed guidance regarding the types of events that should be include d. This definition allows the comparison of prescribing error rates among d ifferent prescribing systems and different hospitals, and is suitable for u se in both research and clinical governance initiatives.