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Complete Prescription Orders Reduce Medication Errors
PREVENTING ERR 0 R S
Complete Prescription Orders Reduce Medication Errors by Michael R. Cohen, MS and Neil M. Davis, PharmD
Despite years of medical training, many physicians begin practicing medicine with bad prescriptionorder-writing habits. Why? Most likely, it's because many medical schools do not offer a solid education in how to write prescription orders. While some medical schools offer second-year students a one- or two-hour lecture on prescription writing' many students are not exposed to the practice until they work with preceptors in their third or fourth year of school. Amazingly enough, most medical students do not get experience in writing orders until they are prescribing in their first year of residency. Pharmacists can help physicians improve their prescription-writing skills through one-on-one discussions. Listed below is essential information pharmacists can pass on to the physicians they work with to help them write clear, accurate prescriptions. Do not assume that your physician colleagues have already heard these suggestions. Some so-called bad habits start because no one ever explained to physiAMERICAN PHARMACY
cians that there is a better way. Physicians want to do what is right, and if you can show them a safer way, they usually will change their prescription-writing habits. The extra time it takes physicians to follow these precautions will help ensure the ultimate goal-that patients are given the medication that was intended to be prescribed. Also, physicians will be well compensated for time taken to improve their prescription writing by not having to answer phone calls from pharmacists who cannot read what is written or by avoiding lawsuits that can result from patients receiving the wrong medication.
states, the order is for a controlled substance, and typing the order is illegal). • Write the patient's full natne since similar names can be easily confused. • State the patient's age in the cases of children and senior citizens. • Print the natne of the drug product if a newly marketed medication is being prescribed. This will prevent pharmacists who may be unfamiliar with a new product from misreading it or from calling the physician for clarification. • Print the natne of the drug when writing an order for an infrequently prescribed product. For example, when a pharmacist is not used to seeing a
prescription order for sulfadiazine tablets 250 mg, he or she can easily mistake the order to be for the more commonly prescribed sul. fasalazine tablets 250 mg. • Indicate the dosage form. If Losec capsules 20 mg were prescribed rather than Losec 20 mg, a mix-up with Lasix would be less likely to occur since Lasix is not available in capsule form. • Always indicate a dosage strength, even if the prescription is for a single-strength product. Although a product may only be marketed in one strength now, additional strengths may be introduced in the future. Indicating dosage strength can prevent
Reporting Medication Errors Pharmacists who encounter medication ennrs can help improve patient safety and perform a valuable service for colleagues by reporting error information to the Medica(MERP), coordinated by tion E " RtIP0rting Progn the t'htes Pharrn tftl Convention/lf(~. rUSP) for the'" . tute Of Safe Me To rej;~rt an ennr, call USP toll-jree, 24 hours a day at 23-ERROR or clo Usp, !
Pointers for Physicians • Write legibly. This is the first step in preventing medication errors and saves pharmacists, nurses, physicians, and patients the time it takes to resolve questions that arise when words are illegible. If a physician cannot write legibly, the prescription order should be typed (unless, as in some
July 1992/560 Vol. NS32, No.7
errors in such cases as a prescription order for Florinef tablets (not Florinef Tablets 100 mcg), which was read as Fiorinal tablets. Seeing "100 mcg" is a tip-off that it is not Fiorinal. • Write complete directions. "As directed" is not acceptable. On occasion, physicians make errors and write an order for the wrong product. When the directions do not match the product, pharmacists can uncover and correct the mistakes. If a prescription order lists the directions, the pharmacist is more able to ensure that the prescription order was interpreted properly and that the drug was prescribed correctly. Directions also give pharmacists an opportunity to provide patient counseling and foster patient compliance . • Include the medication's indication on the
prescription order and ask for it to be put on the medication labeL This too can prevent mistakes by physicians, pharmacists, and patients. There are occasions when a prescribed drug's stated purpose does not appear in the product inserts, such as in the case of tricyclic antidepressants used for treating headaches in nondepressed patients. When physicians write such a prescription order, they can tell their patients that the indication might concern the pharmacist since it is an unusual use. Such uses are well documented in the medical literature. Physicians can write a short note to the pharmacist or otherwise contact the pharmacist. When a pharmacist questions the safety of an offlabel use, he or she should check the literature or contact a local hospital or phar-
macy school's drug information center. While pharmacists should not be obstructionists when a good but unusual therapy is prescribed, they cannot robotically dispense prescription orders that they believe might harm patients. Pharmacists must satisfy themselves about the correctness of prescription orders. • Communicate with the physician in special circumstances. When physicians knowingly prescribe two drugs that have a clinically significant drug interaction, the physician should communicate to the patient and pharmacist that, for this particular patient, this is correct therapy. For instance, some patients who have taken ACE inhibitors and potassium salts have developed life-threatening hyperkalemia. Other patients who take ACE inhibitors have a
Diagnosis: HIV+ There is no cure for HIV. But there are treatment options. The AIDSIHIV Treatment Directory, published by the American Foundation for AIDS Research (AmFAR), is a guide to the full range of approved and experimental treatments. Aone-year subscription to the Directory (4 issues) is only $30.00. To subscribe, or to make a contribution, send your check to AmFAR. ~" ~(~
American Foundation for AIDS Research 1515 Broadway, New York, NY 10036
People with HIV disease who cannot afford a paid subscription may obtain a complimentary copy by calling the National AIDS Information Clearinghouse at 1·800·458·5231.
low serum potassium level and require a potassium supplement. In a case like this, the physician should write on the prescription order for potassium that the patient's serum potassium level is being monitored. This communication will prevent the need for the pharmacist to call the physician, preclude a delay in the patient receiving his or her medication, and prevent the patient from perceiving that there may be a problem with their prescription order. AtichaelR. Cohen, At~ adjunct assistant clinical professor at Temple University, and Neil At. Davis, PharmD, professor ofpharmacy at Temple, are cofounders of the Institute for Safe Atedication Practices, Inc., Huntingdon Valley, Pa.
What Kills More Americans Each Year Than Cocaine, Heroin, Suicide, Alcohol Abuse, Auto Accidents And Homicide Combined? Lung Disease. Including Lung Cancer.
Its a matter of life and breath~ AMERICAN
t ~heU~~~~~~!ATION·
Space contributed by the publisher as a public service.
Vol. NS32, No.7 July 1992/561
AMERICAN PHARMACY
Complete Prescription Orders Reduce Medication Errors by Michael R. Cohen, MS and Neil M. Davis, PharmD
Despite years of medical training, many physicians begin practicing medicine with bad prescriptionorder-writing habits. Why? Most likely, it's because many medical schools do not offer a solid education in how to write prescription orders. While some medical schools offer second-year students a one- or two-hour lecture on prescription writing' many students are not exposed to the practice until they work with preceptors in their third or fourth year of school. Amazingly enough, most medical students do not get experience in writing orders until they are prescribing in their first year of residency. Pharmacists can help physicians improve their prescription-writing skills through one-on-one discussions. Listed below is essential information pharmacists can pass on to the physicians they work with to help them write clear, accurate prescriptions. Do not assume that your physician colleagues have already heard these suggestions. Some so-called bad habits start because no one ever explained to physiAMERICAN PHARMACY
cians that there is a better way. Physicians want to do what is right, and if you can show them a safer way, they usually will change their prescription-writing habits. The extra time it takes physicians to follow these precautions will help ensure the ultimate goal-that patients are given the medication that was intended to be prescribed. Also, physicians will be well compensated for time taken to improve their prescription writing by not having to answer phone calls from pharmacists who cannot read what is written or by avoiding lawsuits that can result from patients receiving the wrong medication.
states, the order is for a controlled substance, and typing the order is illegal). • Write the patient's full natne since similar names can be easily confused. • State the patient's age in the cases of children and senior citizens. • Print the natne of the drug product if a newly marketed medication is being prescribed. This will prevent pharmacists who may be unfamiliar with a new product from misreading it or from calling the physician for clarification. • Print the natne of the drug when writing an order for an infrequently prescribed product. For example, when a pharmacist is not used to seeing a
prescription order for sulfadiazine tablets 250 mg, he or she can easily mistake the order to be for the more commonly prescribed sul. fasalazine tablets 250 mg. • Indicate the dosage form. If Losec capsules 20 mg were prescribed rather than Losec 20 mg, a mix-up with Lasix would be less likely to occur since Lasix is not available in capsule form. • Always indicate a dosage strength, even if the prescription is for a single-strength product. Although a product may only be marketed in one strength now, additional strengths may be introduced in the future. Indicating dosage strength can prevent
Reporting Medication Errors Pharmacists who encounter medication ennrs can help improve patient safety and perform a valuable service for colleagues by reporting error information to the Medica(MERP), coordinated by tion E " RtIP0rting Progn the t'htes Pharrn tftl Convention/lf(~. rUSP) for the'" . tute Of Safe Me To rej;~rt an ennr, call USP toll-jree, 24 hours a day at 23-ERROR or clo Usp, !
Pointers for Physicians • Write legibly. This is the first step in preventing medication errors and saves pharmacists, nurses, physicians, and patients the time it takes to resolve questions that arise when words are illegible. If a physician cannot write legibly, the prescription order should be typed (unless, as in some
July 1992/560 Vol. NS32, No.7
errors in such cases as a prescription order for Florinef tablets (not Florinef Tablets 100 mcg), which was read as Fiorinal tablets. Seeing "100 mcg" is a tip-off that it is not Fiorinal. • Write complete directions. "As directed" is not acceptable. On occasion, physicians make errors and write an order for the wrong product. When the directions do not match the product, pharmacists can uncover and correct the mistakes. If a prescription order lists the directions, the pharmacist is more able to ensure that the prescription order was interpreted properly and that the drug was prescribed correctly. Directions also give pharmacists an opportunity to provide patient counseling and foster patient compliance . • Include the medication's indication on the
prescription order and ask for it to be put on the medication labeL This too can prevent mistakes by physicians, pharmacists, and patients. There are occasions when a prescribed drug's stated purpose does not appear in the product inserts, such as in the case of tricyclic antidepressants used for treating headaches in nondepressed patients. When physicians write such a prescription order, they can tell their patients that the indication might concern the pharmacist since it is an unusual use. Such uses are well documented in the medical literature. Physicians can write a short note to the pharmacist or otherwise contact the pharmacist. When a pharmacist questions the safety of an offlabel use, he or she should check the literature or contact a local hospital or phar-
macy school's drug information center. While pharmacists should not be obstructionists when a good but unusual therapy is prescribed, they cannot robotically dispense prescription orders that they believe might harm patients. Pharmacists must satisfy themselves about the correctness of prescription orders. • Communicate with the physician in special circumstances. When physicians knowingly prescribe two drugs that have a clinically significant drug interaction, the physician should communicate to the patient and pharmacist that, for this particular patient, this is correct therapy. For instance, some patients who have taken ACE inhibitors and potassium salts have developed life-threatening hyperkalemia. Other patients who take ACE inhibitors have a
Diagnosis: HIV+ There is no cure for HIV. But there are treatment options. The AIDSIHIV Treatment Directory, published by the American Foundation for AIDS Research (AmFAR), is a guide to the full range of approved and experimental treatments. Aone-year subscription to the Directory (4 issues) is only $30.00. To subscribe, or to make a contribution, send your check to AmFAR. ~" ~(~
American Foundation for AIDS Research 1515 Broadway, New York, NY 10036
People with HIV disease who cannot afford a paid subscription may obtain a complimentary copy by calling the National AIDS Information Clearinghouse at 1·800·458·5231.
low serum potassium level and require a potassium supplement. In a case like this, the physician should write on the prescription order for potassium that the patient's serum potassium level is being monitored. This communication will prevent the need for the pharmacist to call the physician, preclude a delay in the patient receiving his or her medication, and prevent the patient from perceiving that there may be a problem with their prescription order. AtichaelR. Cohen, At~ adjunct assistant clinical professor at Temple University, and Neil At. Davis, PharmD, professor ofpharmacy at Temple, are cofounders of the Institute for Safe Atedication Practices, Inc., Huntingdon Valley, Pa.
What Kills More Americans Each Year Than Cocaine, Heroin, Suicide, Alcohol Abuse, Auto Accidents And Homicide Combined? Lung Disease. Including Lung Cancer.
Its a matter of life and breath~ AMERICAN
t ~heU~~~~~~!ATION·
Space contributed by the publisher as a public service.
Vol. NS32, No.7 July 1992/561
AMERICAN PHARMACY