American College of Physicians: Internal Medicine — Doctors for Adults ®


Efforts to prevent prescription errors heat up

A different look at the problem and what physicians can do to avoid making the most common mistakes

From the June 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Christine Kuehn Kelly

When it comes to drug errors, physicians have traditionally received most of the blame. Because physicians choose most medications, write the prescription and sign it, they are the ones who take the fall when things go wrong.

Slowly, however, that thinking is beginning to change. Experts are now focusing on the role that health care systems, not just individual physicians, play in medication mishaps. And as organizations examine patterns of drug errors, they are finding that physicians aren't always the culprits.

In fact, experts estimate that up to 28% of all drug mistakes made could have been avoided if there had been some system in place to prevent errors.

One problem in preventing drug errors is that the existing data are imprecise. "No one really knows how many drug errors are being made," said Brian Strom, FACP, a pharmacologic epidemiology specialist at the University of Pennsylvania Medical School. "There's not even a reliable definition of what constitutes an error."

However, there's no question that prescribing mistakes are being made. When the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) investigated 183 sentinel events—unexpected occurrences involving death or serious injury—that took place in hospitals, it found that the majority were a result of medication errors. During a five-year period ending June 1997, the FDA received more than 6,000 reports of medication errors that caused 332 deaths, 235 life-threatening events and 1,273 severe injuries.

Dr. Strom explained that while data on sentinel events are collected, no one is gathering more basic data on how often drug errors cause patients to suffer. "Your prescribing practices may be hurting your patients daily," he said, "and you may not even be aware of it."

That's why a number of organizations are busy building systems to analyze drug mistakes—and help doctors avoid making more. In 1995, for example, the United States Pharmacopeia Convention (USP) created the National Coordinating Council for Medication Error Reporting and Prevention. The goal is to address interdisciplinary causes of drug errors and promote safe use of medications.

As an important first step, the group established the Medication Error Index, which is a framework that links the type of medication error by severity and patient result. The index is significant because it shifts the focus of preventing drug errors away from individual practitioners.

"Finger-pointing when a drug has been misprescribed isolates the individual practitioner," said Jerry Phillips, RPh, from the FDA's Center for Drug Evaluation and Research. "We've discovered there are so many variables in health care that it's usually not a single individual who makes a prescribing error, but a multitude of contributing factors."

Some of the efforts to create safer systems, however, are focusing on physicians. Boston's Institute for Healthcare Improvement (IHI) has already had limited success in reducing drug mistakes by developing strategies that physicians can use. IHI's Collaborative on Reducing Adverse Drug Events and Medical Errors, a collaboration of 40 health care organizations, has reduced drug errors by 30% in those organizations. Successful strategies included increasing light and decreasing clutter in areas where prescriptions are written, reducing time pressures on physicians, adequately training personnel and repeating verbal orders.

While the realization that physicians are not always completely to blame for drug errors is good news, experts say that physicians are far from off the hook. "Physicians need to maintain their role in the therapeutic contract," said Raymond Woosley, FACP, chairman of the pharmacology department of Georgetown University Medical Center. "I always tell patients that we must work together to evaluate the therapeutic response to their medications. I need to know how the medication is working, any side effects that occur, and any reasons for not taking the medication, including financial."

As Dr. Strom from the University of Pennsylvania is quick to point out, prescribing errors are the second largest cause of malpractice claims against physicians. Here are 12 tips to help make sure that you don't become part of that statistic:

  • Be specific. Explain medications and their side effects. Have patients repeat your instructions and tell them what side effects should elicit a call to your office. Use the metric system when possible and spell out "units" rather than writing "U," a common misinterpretation. Even include the patient's age and weight when appropriate.

    It also helps to include a brief notation of purpose, i.e., "For cough." The National Coordinating Council for Medication Error Reporting and Prevention reported one instance in which an order for Haldol (an antipsychotic) was almost filled with Stadol (an analgesic) until the filling pharmacist noted the physician had added "for agitation." In some cases, however, patient confidentiality may preclude this from being done.

  • Write legibly and clearly. It may seem obvious, but more than 15% of the prescription errors in the USP Medication Error Reporting database result from bad handwriting and misinterpretation of medication orders. If necessary for clarity, use block printing. When writing a decimal expression of less than one, write it out as "0.01." Never use a terminal zero: "2.0 mg." Prescribers also should avoid use of abbreviations and Latin directions for use.
  • Provide details. Don't include vague instructions such as "take as indicated" and "resume previous orders." Always rewrite existing orders. Use "mcg," "mg" or "g" for prescription strength instead of "Tylenol 2 tabs."
  • Use brochures. "Prescription Medicines and You: A Consumer Guide" is available in six languages through the National Council on Patient Information and Education and the Agency for Health Care Policy and Research (call 202-347-6711 for an order form). The USP also offers "Customized Patient Education Leaflets" on a variety of drugs. (Call 800-877-6733 to order.)
  • Get information samples. Ask pharmacists to send samples of the information they give patients. "Our studies have shown that 23% don't make written information available, and that 30% to 40% of information is sketchy or misleading," Dr. Woosley said.
  • Take an inventory. Have patients bring in all their medications, including over-the-counter drugs and those prescribed by other physicians. Ask how they take each pill and weed out duplicates of generics and branded drugs. Designate a special place for a detailed medication history in your charts. Dr. Strom asks patients to bring in all their medications every time they come in. "They love it," he said. Other physicians set up a special "brown bag day" to do this, particularly for older patients.
  • Don't cave in. Resist pressure from patients to prescribe certain drugs. With drug advertisements targeting consumers, patients are more likely to request a drug that they've heard about. Reassure patients that the drug you chose for them is more appropriate.
  • Go with what you know. Follow the golden rule of drug therapeutics: Use an old drug instead of a new one. "Don't base your selection on the detail man; use the best drug in its class," said Dr. Strom. Also use the narrowest spectrum drug. "My choice of NSAID is ibuprofen, for example," Dr. Strom said. "It's the oldest and perhaps safest and has many dosage strengths."
  • Look it up. "Unless you are certain of a dose, look it up in a current monograph and incorporate it into your body of knowledge," said Marcus Reidenberg, FACP, professor of pharmacology and medicine and head of the division of clinical pharmacology at Cornell University. "This is especially important when prescribing drugs with clinically meaningful drug interactions."

    And keep translation charts of brand and generic names at hand. "Brand names come and go, but generics are always there," said Dr. Woosley, chairman of the pharmacology department of Georgetown University Medical Center.

  • Use forms. Develop preprinted prescription forms for commonly prescribed drugs. Because you probably use only about 20 drugs on a regular basis, the cost won't be prohibitive.
  • Give technology a try. Electronic prescription writers can help check for incorrect dosages or dangerous drug interactions. Computerized systems also allow providers to automatically fax prescriptions to a pharmacy, store managed care formularies and keep patient histories.
  • Check yourself. Re-read the prescription before you hand it to the patient.

Christine Kuehn Kelly is a Philadelphia-based freelance writer specializing in health care.

The physician's dilemma: to tell or not to tell?

Should you report serious prescribing errors you've made? In most cases, experts say the answer is "yes."

Reporting errors to the FDA or the United States Pharmacopeia Convention (USP) won't endanger physician or patient confidentiality. "The reports are anonymous," said Diane Cousins, RPh, vice president of practitioner reporting systems at USP. "We don't ask who made the error or where it occurred." And FDA regulations protect the identity of the person reporting as well as the identity of the institution associated with the report.

What about advising your patients that you've made a prescribing error? "Honesty is critical," said Herbert Waxman, FACP, the College's Senior Vice President for Education. "Errors with significant impact on a patient must be admitted and discussed with the patient." (For more discussion on this issue, see ACP's ethics case study, "To disclose or not to disclose," on ACP Online at

Practitioners should also keep their colleagues informed of errors. Individual physicians and those in small groups can set up a system to track medication errors. Develop guidelines and make them available to all staff with responsibility for medications. Importantly, the system shouldn't be set up to be punitive, but rather to find ways to prevent errors.

There are two ways to anonymously report medication errors or concerns about product safety, quality or performance:

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