Seven simple steps to prevent outpatient drug errors
From the June ACP Observer, copyright © 2003 by the American College of Physicians.
By Bonnie Darves
SAN DIEGO—In the wake of the widely publicized Institute of Medicine reports on errors, media coverage has focused largely on problems in inpatient settings. But a significant number of medication errors take place in outpatient settings, making it a problem that many internists need to address.
Almost 40% of medication errors take place during the actual prescribing of a drug, said Subramanian Hariharan, MD, director of the neurology residency program at the New Jersey Neuroscience Institute in Edison, N.J.
At an Annual Session presentation on medication errors, Dr. Hariharan outlined some simple steps that internists can take to prevent problems with medications. He pointed out that many medication errors can be traced back to physician fatigue, a hectic work environment, and the failure to double-check medication names, dosages and interactions.
Here are some of the tips Dr. Hariharan offered to cut down on prescribing errors:
1. Check your handwriting. About 16% of physicians still write illegibly, which Dr. Hariharan said is a major factor in medication errors. Hard-to-read handwriting has become an even bigger problem with the growing number of "look-alike" and "sound-alike" drug names and the trend to use faxes to transmit prescriptions.
Even if a pharmacist catches the error or calls to check the drug or dosage, those callbacks create extra work for you and your staff. New electronic prescribing programs that can be used with handheld computers—ePocrates and Allscripts are two of the more popular vendors—are high on Dr. Hariharan's list of recommendations to prevent prescribing errors.
2. Avoid the term "use as directed." Even if patients say they understand your instructions for how and when to take a medication, they often forget the details later when they pick up the prescription. Instead of the "use as directed" notation, write down your instructions on the prescription or in patient notes provided at checkout.
You should also urge patients to review certain information with the pharmacist: the drug name, its indication, common side effects and instructions for taking the medication. (For more on enlisting patients in the fight to prevent errors, see "Don't forget to tap a major safety resource: your patients.")
3. Recheck dosage calculations. Dosage errors are often the result of physician fatigue or interruptions, so recheck your calculations before writing the prescription. (Another advantage of e-prescribing, Dr. Hariharan pointed out: Electronic prescribing systems provide easy-to-use calculation tables.) Also try to write prescriptions in a setting where you won't be interrupted by phone calls or staff questions.
4. Include all pertinent information. It may seem like "overkill," but your prescriptions should include the patient diagnosis; patient-specific data such as age, weight and concurrent diseases or conditions, and known allergies; and the drug's generic and brand name. (Always ask patients about possible allergies before writing a prescription.)
5. Don't use abbreviations. Abbreviations are another common cause of errors. Use "daily" instead of QD or OD; write out "unit" rather than using U (6 U could be misconstrued as 60); use "every other day" instead of QOD; and write out "discontinue" or "discharge" rather than D/C.
6. Avoid decimals. Use 500 mg instead of 0.5 g, for example, and 125 mcg (micrograms) rather than 0.125 mg. You should also avoid using the terminal 0 (as in 1.0 mg). The decimal point might not show up clearly if the paper is lined or the prescription is faxed.
Dr. Hariharan urged physicians to always use the metric system, not the apothecary system. The latter system causes too much confusion, he said.
7. Use pre-typed prescriptions or drug-name ink stamps for frequently prescribed medications. Many practice management systems feature prescribing forms, which reduce the need for handwritten prescriptions. Several drug manufacturers also offer prepared prescription pads for their most widely prescribed drugs.
Dr. Hariharan also urged physicians to avoid verbal prescribing whenever possible. If the situation can't be avoided, he added, take the time to spell out the drug name and confirm that the pharmacist or technician has written down the right dosage and use instructions.
Bonnie Darves is a freelance writer in Lake Oswego, Ore.
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