Preventing Medication Prescribing Errors

1
Preventing Medication Prescribing Errors
2
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

3
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. 19972773127.
4
Common Errors

• Incorrect or inappropriate dosage
• Inappropriate medication for the medical
  condition
• Communication failure between physician and
  patient

5
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

6
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?

7
Standardize Order Communication

• Use standard units (mEq, mg, etc.)
• Include patients weight and/or body surface area
  on drug order
• Include the dose basis to allow an independent
  double check
• mg/kg or mg/m2

8
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

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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

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Abbreviations That Should Never Be Used

• Abbreviation Mistaken for
• u 0
• µg mg
• QOD qd (daily)
• qd qid
• 2
• cc u

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Elements of a Medication Order or Prescription

• Always communicate complete information
• Patients 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

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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

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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

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Therapeutic Category of Prescribed Medication

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Information About the Patient

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

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Drug Information

• Prescribing problems can involve
• Confusion between formulations of
• similarly named products
• Doses beyond safe limits
• Off-label prescribing
• Duplicated therapies

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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

18
Navane Versus Norvasc

• No obvious potential mix-up
• Handwritten prescriptions for these agents have
  resulted in at least 30 cases of medication errors

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Verbal Orders

• Spoken or verbal orders should be avoided
  whenever possible

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Verbal Order for an 18-Month-Old Child

• Get this kid .8 morphine

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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

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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

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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

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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

25
Ambiguous or Incomplete Orders

• Give patient 24 VP-16 capsules before discharge

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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

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Misinterpreted Physicians 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

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Illegible Handwriting
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(No Transcript)
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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. 1979242242930.
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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. 19972615864.
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Handwriting BMJ 1996

• Study of physicians handwriting
• Physicians do not write worse than others in
  health care
• Authors advocate changes in systems so no ones
  handwriting leads to errors

Berwick DM, et al. BMJ.199631316578.
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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. 199762968.
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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

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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

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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

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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

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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

39
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

40
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

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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

42
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

43
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

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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 prescribers
  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 prescribers partner (if there is one) or
  refuse to fill the prescription

45
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 orders safety

46
References

• Anonymous. Study of physicians handwriting as a
  timewaster. JAMA. 1979242242930.
• Berwick DM, Winickoff DE. The truth about
  doctors handwriting a prospective study. BMJ.
  199631316578.
• Brodell RT, Helms SE, KrishnaRao I, et al.
  Prescription errors legibility and drug name
  confusion. Arch Fam Med. 199762968.
• Lesar TS, Briceland L, Stein DS. Factors related
  to errors in medication prescribing. JAMA.
  19972773127.
• Winslow E, Nestor V, Davidoff S. Legibility and
  completeness of physicians handwritten
  medication orders. Heart Lung. 19972615864.