Preventing Medication Prescribing Errors - PowerPoint PPT Presentation

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Preventing Medication Prescribing Errors

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Title: 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

9
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

10
Abbreviations That Should Never Be Used
  • Abbreviation Mistaken for
  • u 0
  • µg mg
  • QOD qd (daily)
  • qd qid
  • 2
  • cc u

11
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

12
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

13
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

14
Therapeutic Category of Prescribed Medication

15
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

16
Drug Information
  • Prescribing problems can involve
  • Confusion between formulations of
  • similarly named products
  • Doses beyond safe limits
  • Off-label prescribing
  • Duplicated therapies

17
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

19
Verbal Orders
  • Spoken or verbal orders should be avoided
    whenever possible

20
Verbal Order for an 18-Month-Old Child
  • Get this kid .8 morphine

21
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

22
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

23
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

24
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

26
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

27
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

28
Illegible Handwriting
29
(No Transcript)
30
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.
31
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.
32
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.
33
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.
34
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

35
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

36
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

37
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

38
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

41
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

44
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.
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