3 Really Common Dosage Form Mistakes

I see so many mistakes when it comes to dosage forms.  More often than not, it doesn’t result in any issues for the patient, but there is always the potential.  Here’s 3 classic dosage form mistakes that I see all the time.

  1. MS Contin – this medication is an extended release morphine intended to control chronic pain.  You should not see this ordered as needed, as the immediate release formulation would be more appropriate to treat acute pain.
  2. Metoprolol succinate versus metoprolol tartrate – Metoprolol succinate is extended release and is “typically” only dose once daily, although I will see it used twice daily on occasion.  Metoprolol tartrate is the immediate release formulation.
  3. Oxycontin – Oxycontin is an extended release product (oxycodone ER).  Again like MS Contin, this should not be used on an as needed basis.  There is an oxycodone immediate release product that can be used as needed for acute relief of pain.

What’s your favorite dosage form mistake?!

If you’ve followed the blog, you maybe remember the morphine post in which there are two different oral liquid concentrations that can end up causing a potential life threatening situation if these are mixed up.

Enjoy the blog? Check out a 6 page PDF on 30 medication mistakes that I see in my everyday practice as a clinical pharmacist! It’s FREE!


  1. Ernest I

    None of those are my favorite. I hate the metoprolol succinate and tartrate dosage form mistake, lol. Our med rec techs in emergency room basically put in what ever the patient says or what ever the their outpatient pharmacy say and then the MDs cosign it and it becomes a inpatient order. This happens almost every other day. And when you page the MD they just say “well that’s what is in the med rec and this is how the patient takes it at home and i don’t want to change it” (90% of doctors don’t want to chage it) really annoying. It has become a route i can sense it that as long as it is in the med rec and its within the maximum daily dose range most pharmacist won’t even page MDs anymore because of the response we get, its sad really but i can’t blame them either as it gets crazy busy when accepting orders. What is your approach Eric just curious and would you know why do we see so many orders of succinate as BID dosing is there a valid reason MDs prescribe it that was? Thanks for the post! I would love to hear from other as well how to approach a situation like that.

  2. Kelly

    My favorite mistake- if they can actually be a favorite is vancomycin IV instead of PO for C. Difficile

  3. Daniel

    We often see physicians accidentally write for single-strength Septra instead of double-strength. For context, our physicians all work in house and write electronic prescriptions via an EHR, meaning they choose the medication on the computer instead of writing it out on paper. As such, I would venture to think this specific error occurs more with electronic rxs versus hand-written rxs.

    • Wade Hodges

      We get this “error” on our electronic system as well. Making it non-formulary would help. At least a phone call would be necessary for approval (in our policy and procedure.)

  4. grant cleveland, pharmd

    The half dozen or so diltiazem formulations, or dilantin

  5. pat donohoo

    depakote er versus depakote dr.

  6. Sean Navin

    Bupropion ER vs SR vs XL is a real pain! It’s definitely confusing for pharmacy and med staff. XL is the only one that is to be dosed once daily while the other two are BID.

  7. Eric Christianson

    Good examples everybody!

  8. Nicole Skyer

    I teach a pharmacy tech certificate course and I always include in my lessons the difference between the different metoprolols, diltiazems and bupropions! So important, right on!

  9. Rajesh

    My Favourites :
    Depakote ER and DR,
    Cardizem CD Cardizem LA and Tiazac

  10. Vidhu

    Lithium, Lithobid and Eskalith…go figure! We have started using generic name with or without ER and then the strength to avoid confusions. Yet, the Psychiatrists are so comfortable with the brand names.


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Written By Eric Christianson

January 17, 2016

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