Preventing Medication Prescribing Errors

Learning Objectives

• Describe error reduction strategies related to the prescribing process

• Discuss the safety value of preprinted order sets

• Explain the medication reconciliation process

• Discuss conflict resolution as it relates to troublesome medication orders

Extent of Prescribing Errors

• Hospital-based study evaluating medication prescribing errors found overall rate of 3.99 clinically significant errors per 1,000 orders over a 1-year period:– 14%: failure to change drug therapy with hepatic

or renal dysfunction– 12%: failure to recognize allergy to the

medication class– 11%: use of an incorrect drug name, dosage

form, or abbreviation– 11%: use of an atypical or unusual, but critical

dosage frequency

Lesar TS, et al. JAMA. 1997;277:312–7.

Common Errors

• Incorrect or inappropriate dosage

• Inappropriate medication for the medical condition

• Communication failure between physician and patient

Communication of Drug Information

• Barriers that lead to ineffective communication dynamics– Unclear order communication– Illegible handwriting– Dangerous abbreviations and dose

designations– Verbal orders– Ambiguous orders

Standardize Order Communication

• Eliminate verbal orders • Use generic and brand names

– Do not abbreviate drug names• “Neo stick” — Neo-Synephrine or neostigmine?

• Do not refer to drugs by class name – Is “platinum” carboplatin or cisplatin?

• Never prescribe only by volume or number of vials or ampuls– “Digoxin 0.7 mL daily by mouth”

• What strength — 0.25 mg/mL or 0.1 mg/mL?

Standardize Order Communication

• Use standard units (mEq, mg, etc.)

• Include patient’s weight and/or body surface area on drug order– Include the dose basis to allow an

independent double check• mg/kg or mg/m2

Order-Writing Practices

• Misuse of decimals Wrong Right

.1 mg 0.1 mg

1.0 mg 1 mg

• Way to remember: if the decimal is not seen, 10-fold error might be made

Order-Writing Practices

• Use spaces between name of medication and dose, as well as between the dose and the units– Propranolol30mg – looks like l30mg

instead of Propranolol 30 mg

Abbreviations That Should Never Be Used

Abbreviation: Mistaken for: u 0

μg mg QOD qd (daily) qd qid

& 2 cc u

Elements of a Medication Order or Prescription

• Always communicate complete information– Patient’s full name and location

– Applicable patient-specific data (e.g., allergies, age, weight)

– Generic and brand name, if possible

– Drug strength in metric units by weight

– Dosage form

– Amount to be dispensed, expressed in metric units

Elements of a Medication Order or Prescription (continued)

– Complete directions for use, including route of administration and frequency of dosing (never “take as directed”)

– Number of refills or duration of therapy– Purpose of the medication

Purpose of a Medication

• Including the purpose for a medication provides the pharmacist, nurse, and patient with additional assurance that they have the correct medication

• Patients should be educated to ask their prescribers to include the purpose of the medication on all of their prescriptions

Therapeutic Category of Prescribed Medication

Information About the Patient

• Proper prescribing requires knowledge of the patient’s:– Renal and hepatic function– Age and weight– Concurrent medications including OTCs– Allergies/drug sensitivities– Pregnancy status– Medical and family history

Drug Information

• Prescribing problems can involve:– Confusion between formulations of

similarly named products

– Doses beyond safe limits

– Off-label prescribing

– Duplicated therapies

Look-Alike or Sound-Alike Drug Names

• Written drug names on prescriptions may look like other similar drug names

• Many drug names may sound like other agents and verbal orders must be handled very carefully

Navane Versus Norvasc

• No obvious potential mix-up

• Handwritten prescriptions for these agents have resulted in at least 30 cases of medication errors

Verbal Orders

• Spoken or verbal orders should be avoided whenever possible

Verbal Order for an 18-Month-Old Child

“Get this kid .8 morphine”

Safety Recommendations for Spoken Orders

• Limit verbal orders to true emergencies or when prescriber is physically unable to write or electronically transmit orders

• Limit spoken orders to formulary drugs• Prohibit spoken orders for high-alert

medications • Limit personnel who may receive

telephone or spoken orders

Safety Recommendations for Spoken Orders

• Whenever possible, have a second person listen to the spoken order

• Provide physicians’ offices with appropriate forms so orders may be faxed or electronically transmitted, especially for new patients

• Establish time frame for prescribers to validate (sign) verbal orders

Safety Recommendations for Spoken Orders

• Prescribers should spell unfamiliar drug names (e.g., saying “T as in Tom” or “C as in Charlie”)

• Prescribers should pronounce each digit of a number separately (e.g., saying “one six” instead of “sixteen” to avoid confusion with “sixty”)

• Prescribers should provide pager or telephone number for questions that arise

Safety Recommendations for Spoken Orders

• Prescribers should speak slowly and clearly• Receivers should write the order onto a

prescription or into the medical record and then read back the order to the prescriber to verify it is correct

• Receivers should not accept spoken orders when the prescriber is present– Exception: surgeon who is “scrubbed in”

Ambiguous or Incomplete Orders

“Give patient 24 VP-16 capsules before discharge”

Prevent Prescription Errors

• Include patient diagnosis or purpose of therapy• Write legibly: PRINT, PRINT, PRINT• Do not use “As Directed” unless more complete

directions are also given on another paper (e.g., complex tapering dosage)

• Include patient data if relevant (height, weight, age, body surface area)

• Include dosage form needed • Provide complete directions for use

– Do not abbreviate route of administration• Indicate pregnancy status if patient is pregnant• Inform patient about medication prescribed

Misinterpreted Physician’s Prescriptions

Study showed that medication errors related to misinterpreted physicians’ prescriptions were the second most prevalent and expensive claim listed on 90,000 malpractice claims filed over a 7-year period

Illegible Handwriting

Handwriting: JAMA 1979

• A study of physicians’ handwriting and wasted time– 47 staff physicians in a 500-bed teaching

hospital– 16% illegible writing– 17% barely legible writing– Best writing — cardiac surgeons– Worst writing — general surgeons

Anonymous. JAMA. 1979;242:2429–30.

Handwriting: Heart & Lung 1997

• Physicians’ handwritten orders– Tertiary hospital in Texas; 176 orders,

55 physician signatures; 39 physicians– 20% of the orders and 78% of the

signatures were illegible– 24% of medication orders incomplete

(18% omitted date and 57% had time missing)

Winslow E, et al. Heart Lung. 1997;26:158–64.

Handwriting: BMJ 1996

• Study of physicians’ handwriting– Physicians do not write worse than others

in health care– Authors advocate changes in systems so

no one’s handwriting leads to errors

Berwick DM, et al. BMJ.1996;313:1657–8.

Handwriting: Arch Fam Med 1997

• Suggestions by physician authors regarding legibility:– Physicians should assess their own

handwriting skills and prescribing habits– Use typed, preprinted prescription pads– Make use of staff assistants with excellent

penmanship

Brodell RT, et al. Arch Fam Med. 1997;6:296–8.

Handwriting: Arch Fam Med (continued)

– Print, spell out the word “units,” avoid slashes and trailing zeros

• Do put a leading zero (0) in front of a decimal value less than 1

– Complete instructions on each prescription, including purpose of medication

– Encourage, rather than discourage, pharmacists to call if they see any discrepancy in a prescription

Handwriting: Arch Fam Med (continued)

– Encourage patients to bring all of their medications with them

– Provide careful verbal patient education– Consider the possibility of inadvertent drug

substitution when side effects are reported– Utilize computer software available for

computer-generated prescription writing

Recommendations for Safe Design of Preprinted Orders

• Obtain multidisciplinary input when designing preprinted orders

• Use generic names – Include brand names for single-source drugs

• Avoid coined names and jargon• Do not use dangerous abbreviations• Express doses in metric weight• Specify reason for each prescribed

medication whenever possible

Recommendations for Safe Design of Preprinted Orders

• For chemotherapy orders, list dosage per square meter – Also include daily dose and the number of

days the drug should be given

• For pediatric orders, include dosage per kilogram when a calculated dose must be entered

Recommendations for Safe Design of Preprinted Orders

• Enhance readability by using professional quality fonts and print style

• Include tracking number and revision date on the form to ease replacement

• Omit lines on back copies of any carbonless order form to avoid obscuring decimal points

• Review all preprinted orders or order sets every 2 to 3 years or when protocols change

Computerized Prescriber Order Entry (CPOE)

• Prevents poorly written prescriptions, improper terminology, ambiguous orders, and omitted information

• Institute of Medicine recommends that all prescribers should be using CPOE by 2010

• CPOE has the potential to halve medication errors

Medication Reconciliation

• Poor communication of medical information at transition points is responsible for up to 50% of all medication errors and up to 20% of adverse drug events in hospitals

• The Joint Commission has made a National Patient Safety Goal (NPSG) requiring hospitals, ambulatory care settings, and long-term care organizations to “reconcile medications across the continuum of care”

Medication Reconciliation

• Obtain list of current medications including OTC preparations – Visual inspection of the pre-admission

medications may be helpful

• Prescriber must consider the medication list when prescribing admission medications

• Discrepancies must be reconciled

Medication Reconciliation

• Reconciliation of the medication list is performed again upon transfer and discharge

• Medication list should be shared with the next provider of service

• Clear instructions must be given to patients regarding which of their pre-admission medications have been changed or discontinued

Intimidating Prescribers

• Institute for Safe Medication Practices survey results noted that 7% of 2,000 health care professionals responding said they had been involved in a medication error in the previous year in which intimidation played a role

• Organizations should enforce a zero tolerance policy for intimidation

Resolving Conflicts in Drug Therapy

• If a pharmacist is not satisfied that a patient will not be harmed and the prescriber will not change the order — consult with prescriber’s chief resident, chief attending physician, department chairperson, or a specialist in the area of the drug therapy ordered

• In the community, a pharmacist might consult with the prescriber’s partner (if there is one) or refuse to fill the prescription

Resolving Conflicts in Drug Therapy

• Clinicians should refuse to administer or dispense a drug if they are reasonably sure that withholding it is the safest action

• An ad hoc peer group may be necessary to determine an order’s safety

References

Anonymous. Study of physicians’ handwriting as a timewaster. JAMA. 1979;242:2429–30.

Berwick DM, Winickoff DE. The truth about doctors’ handwriting: a prospective study. BMJ. 1996;313:1657–8.

Brodell RT, Helms SE, KrishnaRao I, et al. Prescription errors: legibility and drug name confusion. Arch Fam Med. 1997;6:296–8.

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312–7.

Winslow E, Nestor V, Davidoff S. Legibility and completeness of physicians’ handwritten medication orders. Heart Lung. 1997;26:158–64.