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Overcoming Prescribing Errors Not a Bitter Pill

Georgette Samaritan, RN, BSN

Reprinted with permission from MAG Mutual Insurance Company, Healthcare Risk Manager, Volume 12 / Number 13 2006

Medication prescribing errors occur all too frequently. A few key items can spell disaster on a prescription pad: a patient’s changing or declining kidney function, a patient’s documented drug allergy, the wrong drug name or abbreviation, incorrect dosage calculations, and unusual or critical dosage/frequency considerations. These contributing factors are relatively easy to recognize, and most of the time easy and inexpensive to fix. The Malpractice Experience The Physician Insurers Association of America (PIAA) Data Sharing Reports identify “prescription of medication” as the second most frequent and second most expensive procedure in claims against physicians insured by PIAA member companies like MAG Mutual. A 2006 PIAA report reveals that the medical specialties with the highest number of medication related claims were Family Practice and Internal Medicine. Family Practice and Internal Medicine also had the highest total indemnities paid of all specialties. A claims analysis conducted by the Harvard Risk Management Foundation (RMF), found that medication-error claims closed with payment more frequently than all claims, and that the payments were substantially higher. Regarding classes of drugs most frequently involved, the study found that more than 60 percent of alleged errors in liability claims were associated with the following five drug groups:

• Antibiotics

• Anticoagulants

• Steroids

• Narcotics

• Cardiovascular drugs

These findings are similar to those reported by the PIAA in its 1993 Medication Errors Study.

Types and Causes of Errors According to the PIAA, the greatest risk in prescription errors is for the physician rather than the pharmacist. The predominant root cause of prescribing errors is a lack of knowledge about the drug to be administered, as well as a lack of detailed and timely information about the patient who is to receive the drug. Patients with kidney conditions, liver conditions, or known drug allergies are at great risk. An Institute of Medicine (IOM) report cites the following factors as causal in medication errors:

• Failure to alter a medication or dosage due to patient’s reduced kidney or liver function

• Known allergy to same medication class

• Using the wrong drug name, dosage form or abbreviation

• Incorrect dosage calculation and decimal point misplacements

● Atypical or unusual and critical dosage frequency considerations

Low-Cost, Common-Sense Initiatives to Reduce Errors in Prescription Writing

• Prescribers should print prescriptions clearly

• Prescription orders should include a brief notation of purpose (e.g. for cough), unless considered inappropriate by the prescriber

• All prescription orders should be written in the metric system except for therapies that use standard units such as insulin, vitamins, etc.

• Units should be spelled out rather than writing “U”

• Prescribers should include age and, when appropriate, weight of the patient on the prescription or medication order

• The medication order should include drug name, exact metric weight or concentration and dosage

• A leading zero should always precede a decimal expression of less than one. A terminal or trailing zero should never be used after a decimal

• Review and post the ISMP’s List of Error-Prone Abbreviations, Symbols and Dose

designations: Remind all prescribers to avoid the use of abbreviations including those for drug names, like MOM, HCTZ and Latin directions for use

• Prescribers should not use vague instructions such as “take as directed” or “take/use as needed” as the sole direction for use

• Recognize the need for dose adjustment in children and elderly patients

• Recognize the hazards of poly-pharmacy, drug/ drug interactions and possible adverse effects

• When co-managing patients with other physicians, make sure that the individual areas of Responsibility are clearly documented in the patient’s record (e.g., who is managing the dosage and monitoring the response or complications)

• Encourage patients with multiple physicians, prescriptions or complicated medication regimens to use one pharmacy

• Ensure ongoing physician education on new drugs, new uses, unusual uses, etc. and use guidelines from professional organizations

• Instruct staff to always verify questionable or illegible orders with the prescribing physician and encourage staff to ask questions

Verbal or Telephone Orders Verbal or telephone orders present special problems. They can easily be misheard or misinterpreted, transcribed incorrectly, or not recorded in a patient’s chart. They may also be incomplete and confusing. Ideally, verbal orders should be accepted only in emergency situations. Physician’s offices should institute a firm policy for regulating verbal or telephone orders. Include the following:

• Ensuring that a caller is properly identified as the individual’s physician or other authorized prescriber. Some facilities may use a password/ code system to authorize prescribers

• Identifying the patient

• Ensuring that the prescriber is available by phone or other means to confirm or clarify an order if questions arise

• Ensuring that the order is recorded in the chart immediately and later authenticated by the authorized prescriber within a stated amount of time

• Ensuring that recipients verify the order by reading it back as it is written. The patient’s record should document that the order was “repeated and confirmed”

• Spelling out all drug names, however simple, and specifying doses carefully

References PIAA Data Sharing Project, June 2006 Dwyer K, Medication-Related Malpractice Claims, Forum 1998 Fall:19 (4):4-7 Medication Error Study. Physician Insurers Association of America,Washington, DC. June 1993. Institute of Medicine (IOM), “To Err Is Human: Building a Safer Health System”. 2000, online Bettman JW. Seven Hundred Medicolegal Cases in Ophthalmology. Ophthalmology. 1990; 97: 1379-84. National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) c/o U.S. Pharmacopeia NCC MERP Secretariat 12601 Twinbrook Parkway Rockville, MD 208052 (301) 816-8265, www.nccmerp.org Institute for Safe Medication Practices, Suite 810, 1800 Byberry Road, Huntingdon Valley, PA 19006 (215) 947-7797, www.ismp.org