Transcript Misinterpreted Physician’s Prescriptions

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
.1 mg
1.0 mg
Right
0.1 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:
u
μg
QOD
qd
&
cc
Mistaken for:
0
mg
qd (daily)
qid
2
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.