OSCESup.com — Prescribing Safety Check · Alan Park

OSCESup.com

Prescribing Safety Check
Day 2 Post-NSTEMI

Mr Alan Park · 58 · Male · Cardiology Ward · Post-PCI

6 errors hidden Y2 / Finals Cardiology Post-MI prescribing

🔍

How to use this exercise

This prescription chart looks like a real drug chart — no errors are marked. Work through it systematically as you would in clinical practice. Click any cell, field or row to check it.

If you find an error, the cell will reveal what's wrong and what the correct prescription should be. Correct cells will briefly confirm they're fine. There are 6 errors hidden somewhere on this chart — find them all.

Errors found

0 / 6

Northbridge General Hospital NHS Trust

Acute Inpatient Medication Administration Record

Chart No: 2
Ward: Cardiology

Surname PARK

✓ Correct

First name Alan

✓ Correct

Date of birth 14 / 03 / 1964

❌ Error 1 — Wrong date of birth

DOB recorded as 1964, making the patient 62 years old. Mr Park is 58, born 14/03/1966.

✓ Correct: 14 / 03 / 1966. Always verify patient identity using two identifiers (name + DOB) before prescribing or administering any medication. DOB errors risk wrong-patient administration.

Hospital No. NB-447821

✓ Correct

Weight 88 kg

✓ Correct

Consultant Dr S. Mehta

✓ Correct

Date of admission 20 / 02 / 2026

✓ Correct

Diagnosis NSTEMI — post-PCI day 2 (DES to LAD)

✓ Correct

⚠ Allergies & adverse reactions NKDA — No Known Drug Allergies Signed: Dr T. Rees · 20/02/26

✓ Allergy section completed and signed — correct

Clinical context — Day 2 post-NSTEMI. PCI + drug-eluting stent (DES) to LAD performed yesterday. Contrast angiogram 24h ago. eGFR today 68. K⁺ 4.2 mmol/L. BP 118/74. HR 62 sinus rhythm. Currently eating and drinking.

Regular medications — post-PCI day 2

#	Drug (approved name)	Dose	Route	Frequency	Start date	Indication	Prescriber / notes
1	— no entry — ❌ Error 2 — Omission: aspirin not prescribed After PCI with a drug-eluting stent (DES), dual antiplatelet therapy (DAPT) is mandatory for a minimum of 12 months. DAPT = aspirin + a P2Y12 inhibitor (ticagrelor). Ticagrelor is prescribed on row 2, but aspirin has been completely omitted. Without aspirin, stent thrombosis risk increases significantly. ✓ Correct: Aspirin 75 mg OD PO — continue indefinitely post-PCI. Ticagrelor 90 mg BD continues alongside for 12 months (DAPT). Do not stop either without cardiology advice. ⚠ Stent thrombosis risk — potentially fatal
2	TICAGRELOR ✓ Correct drug	90 mg ✓ Correct dose	PO ✓ Correct route	BD ✓ Correct frequency	21/02/26 ✓ Correct	DAPT — post-DES ✓ Correct	Dr T. Rees · GMC 7823441 ✓ Correct
3	ATORVASTATIN ✓ Correct drug	80 mg ✓ Correct dose	PO ✓ Correct route	OD nocte ✓ Correct frequency	21/02/26 ✓ Correct	High-intensity statin ✓ Correct	Dr T. Rees · GMC 7823441 Take at night ✓ Correct
4	RAMIPRIL ✓ Correct drug (ACEi indicated post-MI)	10 mg ❌ Error 3 — Wrong dose: ramipril started too high Ramipril 10 mg is a fully-titrated maintenance dose. Starting at 10 mg post-MI causes dangerous first-dose hypotension, which can be severe in patients with borderline blood pressure post-infarct. This patient's BP is 118/74 — already relatively low. ✓ Correct: Start ramipril at 2.5 mg OD (or 1.25 mg if systolic <120). Titrate slowly: 2.5 → 5 → 10 mg over weeks, checking BP and renal function at each step (NICE NG185).	PO ✓ Correct route	OD ✓ Correct frequency	21/02/26 ✓ Correct	Post-MI — ACEi ✓ Correct indication	Dr T. Rees · GMC 7823441 ✓ Correct
5	BISOPROLOL ✓ Correct drug (beta-blocker indicated post-MI)	10 mg ❌ Error 4 — Wrong dose: bisoprolol starting dose too high Bisoprolol 10 mg is a high maintenance dose. Starting beta-blockade at 10 mg post-MI causes profound bradycardia and hypotension. At HR 62 and BP 118/74, this patient is at significant risk of haemodynamic compromise from a high starting dose. ✓ Correct: Start bisoprolol at 1.25 mg OD. Titrate slowly every 2 weeks: 1.25 → 2.5 → 3.75 → 5 → 7.5 → 10 mg, tolerating HR ≥50 and SBP ≥90 at each step (ESC post-MI guideline).	PO ✓ Correct route	OD ✓ Correct frequency	21/02/26 ✓ Correct	Post-MI — beta-blocker ✓ Correct indication	Dr T. Rees · GMC 7823441 ✓ Correct
6	FUROSEMIDE ✓ Correct drug (loop diuretic for HF)	500 mg ❌ Error 5 — Wrong dose: furosemide 500mg (10× standard dose) Furosemide 500 mg is ten times the standard starting dose. This dose is occasionally used in resistant oedema in renal failure patients under specialist supervision — it is completely inappropriate here. This would cause severe electrolyte derangement (hypokalaemia, hyponatraemia), acute kidney injury, and dangerous hypotension. ✓ Correct: Furosemide 40 mg OD PO is the standard starting dose for mild heart failure or mild fluid overload post-MI. Titrate according to daily weights and renal function. Monitor U&E closely. ⚠ 10× overdose — severe electrolyte disturbance / AKI risk	PO ✓ Correct route	OD (morning) ✓ Correct frequency	21/02/26 ✓ Correct	Fluid overload — post-MI ✓ Correct indication	Dr T. Rees · GMC 7823441 ✓ Correct
7	METFORMIN ❌ Error 6 — Metformin not withheld post-contrast angiogram Mr Park had a contrast angiogram 24 hours ago. Metformin must be withheld for 48 hours after iodinated contrast due to the risk of contrast-induced nephropathy (CIN), which causes acute renal impairment, metformin accumulation, and metformin-associated lactic acidosis (MALA). ✓ Correct: Withhold metformin for 48 hours post-contrast (until 22/02/26). Check U&E and eGFR at 48h — if eGFR stable ≥45, restart metformin. If eGFR has fallen, seek senior review before restarting (MHRA guidance). ⚠ Lactic acidosis risk post-contrast	1g ✓ Dose correct (if withheld appropriately)	PO ✓ Correct route	BD ✓ Correct frequency	21/02/26 ✓ Note: this drug should be withheld post-contrast — check the drug name cell	Type 2 diabetes ✓ Correct indication	Dr T. Rees · GMC 7823441 ✓ Correct
8	PARACETAMOL ✓ Correct drug	1g ✓ Correct dose	PO ✓ Correct route	QDS PRN ✓ Correct frequency	21/02/26 ✓ Correct	Analgesia PRN ✓ Correct	Dr T. Rees · GMC 7823441 ✓ Correct
9	OXYGEN ✓ Correct — oxygen prescribed as a drug with target saturation	Target SpO₂ 94–98% ✓ Correct target for this patient (no COPD)	Inhaled ✓ Correct route	PRN — titrate ✓ Correct — only if SpO₂ below target	21/02/26 ✓ Correct	Hypoxaemia ✓ Correct indication	Dr T. Rees · GMC 7823441 Wean if SpO₂ >94% ✓ Correct

Prescribing doctor Dr T. Rees FY2

✓ Signed

GMC number 7823441

✓ GMC number present

Bleep 4421

✓ Contact details present

Date / time 21/02/2026 · 08:30

✓ Date and time documented

Click any cell on the prescription chart above to check it · 6 errors are hidden somewhere

Answer guide

6 errors

E1 Wrong date of birth — 1964 instead of 1966 Admin error ▼

As prescribed

DOB: 14 / 03 / 1964 (age 62)

Correct

DOB: 14 / 03 / 1966 (age 58) — Mr Alan Park

Prescribing to the wrong patient or using the wrong identifying information is a medication safety never event. Two patient identifiers — full name and date of birth — must be verified against the patient's wristband before prescribing or administering any medication. A 2-year DOB error on a drug chart could result in wrong-patient drug administration if a second patient with a similar name is on the same ward.

E2 Aspirin omitted — DAPT incomplete after drug-eluting stent Omission ▼

As prescribed

Ticagrelor 90 mg BD only — aspirin not prescribed

Correct

Aspirin 75 mg OD + ticagrelor 90 mg BD (DAPT) — both required for minimum 12 months post-DES

After percutaneous coronary intervention (PCI) with a drug-eluting stent (DES), dual antiplatelet therapy (DAPT) is the gold standard to prevent in-stent thrombosis. DAPT = aspirin (COX-1 inhibitor) + a P2Y12 inhibitor (ticagrelor or clopidogrel). Both mechanisms are needed: aspirin alone is insufficient to prevent stent thrombosis, and ticagrelor alone leaves thromboxane A₂-mediated platelet activation unblocked. ESC and NICE guidelines: continue DAPT for 12 months post-DES unless major bleeding occurs. Stopping aspirin significantly increases stent thrombosis risk.

⚠ Stent thrombosis risk — potentially fatal

E3 Ramipril 10 mg — too high a starting dose post-MI Wrong dose ▼

As prescribed

Ramipril 10 mg OD — first post-MI dose

Correct

Ramipril 2.5 mg OD starting dose, titrate over weeks to 10 mg OD target (NICE NG185)

ACE inhibitors are commenced at the lowest dose after MI because the renin-angiotensin system is upregulated in the peri-infarct period. Starting at 10 mg causes first-dose hypotension, which reduces coronary perfusion in an already ischaemic myocardium. BP of 118/74 already indicates the patient is at risk of hypotension. NICE NG185 and SIGN 148 both specify starting at 2.5 mg and titrating. Blood pressure and renal function must be checked before each dose increase.

E4 Bisoprolol 10 mg — maximum dose started immediately post-MI Wrong dose ▼

As prescribed

Bisoprolol 10 mg OD — first post-MI dose

Correct

Bisoprolol 1.25 mg OD starting dose, titrate every 2 weeks to target 10 mg OD (ESC guideline)

Beta-blockers must be introduced at low doses and gradually up-titrated post-MI to avoid haemodynamic compromise. At HR 62, prescribing 10 mg bisoprolol risks symptomatic bradycardia, heart block, and worsening cardiogenic shock if any degree of left ventricular dysfunction is present. The target of 10 mg is achieved over months — not on day 2. Both the ACEi and beta-blocker being started at maximum doses simultaneously compounds this risk substantially.

⚠ Bradycardia and hypotension risk — compounded with ramipril error

E5 Furosemide 500 mg — 10× the standard dose Wrong dose ▼

As prescribed

Furosemide 500 mg OD PO

Correct

Furosemide 40 mg OD PO — standard starting dose for fluid overload

The standard oral furosemide dose for mild heart failure and fluid overload is 40 mg once daily in the morning. 500 mg doses are occasionally used in end-stage renal failure under specialist supervision. In this patient, 500 mg furosemide would cause catastrophic electrolyte derangement (severe hypokalaemia, hyponatraemia, hypomagnesaemia), acute kidney injury from volume depletion, and dangerous hypotension. In the context of also receiving ramipril 10 mg and bisoprolol 10 mg, this chart compounds three separate haemodynamic hazards simultaneously.

⚠ Severe electrolyte disturbance / acute kidney injury

E6 Metformin not withheld — 24 hours post-contrast angiogram Contraindicated ▼

As prescribed

Metformin 1g BD continued day after contrast angiogram

Correct

Withhold metformin for 48 hours after iodinated contrast. Recheck U&E at 48h — restart only if eGFR remains ≥45 (MHRA guidance)

Iodinated contrast agents can cause contrast-induced nephropathy (CIN), reducing eGFR transiently. Metformin is renally excreted — if renal function deteriorates, metformin accumulates and inhibits hepatic lactate metabolism, causing metformin-associated lactic acidosis (MALA) with mortality up to 50%. Current MHRA guidance (2022) states metformin should be withheld for 48 hours after contrast, with U&E checked before restarting. This applies regardless of baseline renal function. Remember SADMANS for all acute admissions and procedural contexts.

⚠ Lactic acidosis risk post-contrast