Ramzi Shawahna, Nisarur Rahman.
Prescribing errors involved splitting of tablets: a two-hospital case analysis.
Pak J Med Health Sci Jul ;2(2):54-8.

Objectives: To decide on whether tablet splitting scenarios represent prescribing error situations or not by a panel of expert judges composed of thirty members and to analyze splitting of tablets orders in two teaching hospitals. Methods: A questionnaire containing scenarios was submitted to each member of the panel of expert judges, and a two round Delphi technique was followed to obtain consensus. Based on the Delphi rounds results, 902 and 316 medication orders were screened from Services hospital and Punjab Institute of Cardiology, respectively. Results: Two scenarios were considered prescribing error situations, one was excluded and one was partially agreed upon. In Services Hospital 42 errors were detected, out of which 20 errors involved splitting of modified release tablets while 22 errors involved splitting of coated tablets. In Punjab Institute of Cardiology 41 errors were detected, out of which 23 errors involved splitting of modified release tablets while 18 errors involved splitting of coated tablets. Conclusion: It was concluded that programs are needed to increase the current awareness regarding unsuitability of splitting all tablet types.

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