Enhancing Your Practice

To err is human:
How to prevent medical errors

A recent IOM report raised awareness of the seriousness and extent of hospital-based errors. But mistakes occur in office practices, as well. Our experts give advice on how to avoid medical missteps.

The pharmacist called this morning with a query about one of the prescriptions that you wrote. He thought a decimal point was in the wrong place, and he was right. How often have similar mistakes gone unnoticed? Since the Institute of Medicine (IOM) report on medical errors was published, the media have been focusing on hospital-based mistakes because those were the subject of the report.¹ But mistakes occur in the primary care office on a daily basis, and some of them are never discovered. Does a remedy exist?

The medical-errors arena is undergoing a transformation. Experts now recommend looking not at individuals, but at systems and processes as the critical sources of most mistakes. The focus has shifted to designing office procedures so mistakes are caught before they affect patients. Because problems cannot be solved until they are identified, staffers must be enabled to move away from a punitive culture that assigns blame for mistakes. Individual employees must be relatively free to report errors—and near misses—without fear of reprisal. Some institutions go so far as to send thank-you letters to employees who report mistakes.

A NEW AWARENESS

The report released by the IOM in November 1999 stated that between 44,000 and 98,000 hospital patients die each year from preventable medical errors.¹ To Err Is Human: Building a Safer Health System stated that more people die each year from errors than from breast cancer or motor vehicle accidents; more than half of those deaths were preventable. Even though some experts question the way the statistics were compiled, the document has raised concerns among physicians and patients.

About the numbers

Are the IOM's statistics exaggerated, or are they underestimated? Some experts point out that patients in hospitals are sicker and more likely to die even before they are admitted.² Furthermore, say these experts, both the high and low figures were extrapolated from studies that analyzed adverse events and poor outcomes, not true errors. In contrast, those who believe the IOM projections are conservative point out that most injuries and errors do not find their way into medical records.³

Extrapolating to the office setting

The IOM data were extrapolated from chart reviews of New York, Colorado, and Utah hospitals. Chart review by definition misses a number of cases where errors have occurred but are undocumented, say the experts. In addition, the IOM statistics relate to only hospital-based injuries; office-based care represents a larger sector of the health care industry. The office-based physician is called upon to manage increasing numbers of new medications with potentially dangerous adverse effects and interactions. In addition, therapies are increasingly complex to administer.

MEDICATION ERRORS

Errors result from prescribing mishaps, communication gaps, and a distracted staff. More than 7000 deaths occurred in 1993 due to medication errors resulting from incorrect dosages and drug names and faulty patient instructions. That represents a substantial increase from 2900 in 1983, according to the IOM.¹

Writing prescriptions carefully

According to a report from the United States Pharmacopeia (USP) on data from its national database, MedMARx, the 3 most frequently reported types of errors were

• Omission errors (an ordered dose was not administered)

• Dosage errors (a dosage, strength, or quantity differed from that prescribed)

• Authorization errors (the medication dispensed was not authorized).⁴

The report revealed that the primary factors that contributed to mistakes were distractions and workload increases. Insulin, heparin, and warfarin were the drugs most often associated with errors. In a third of cases, the personnel who initiated or perpetuated the errors were not informed of their role.

Mistakes in prescription writing can range from insignificant to fatal and tend to be a result of poor communication, rushing, and carelessness on the part of staff members:

Illegible handwriting Consider printing or having your prescriptions typed. Many abbreviations can easily be misunderstood by pharmacists and nurses. For example when insulin, 6U, is prescribed, nurses could interpret the dosage as 60—seeing the U as a zero—resulting in a massive overdose (see Table 1). The remedy is to take the time to write out "6 units."

Careless prescribing When prescribing, check medications even if you are familiar with them, and look up those unfamiliar to you. Between 8000 and 9000 drugs are available today, compared with about 500 just 30 years ago. Even if you routinely prescribe just 30 to 40 drugs, you need to understand the indications, contraindications, warnings, interactions with other drugs, side effects, complications, and any laboratory tests required before or during therapy. When dispensing samples, be as vigilant as when prescribing—check for the appropriateness of dosages as well as for allergies and drug interactions. You also need to make sure that you know about the patient's drug sensitivities and allergies and all the other medications being taken. Make certain that someone is available to respond quickly to a phone call from nurses or pharmacists questioning something you wrote. Also double-check placement of decimal points.

Mistaking names Confusion over the similarity of drug names accounts for about 25% of all errors resulting in reports to the USP Medication Errors Reporting Program. More than 1000 name pairs that have been confused on prescriptions have been identified (see Table 2 and http://www.usp.org/reporting/review/qr66.pdf ). Similar sounding drug names with totally different therapeutic indications and side effects can be easily confused.

Keeping yourself and your patients educated

Other causes of medication-related errors include

Underinformed patients Educating patients about their conditions and the prescribed therapies is a way of avoiding errors. An estimated 30% to 50% of patients do not adhere to their prescription regimens. Do not shortcut your instructions. Patient education is especially important when prescribing newly approved medications. Make sure patients understand the importance of taking the correct dosages. For example, clarify that taking several doses at once to catch up on missed doses could be dangerous.³ Clearly describe what the medication is for and how it is supposed to be taken. Encourage the use of medication dispensers with compartments for the dosages taken each day or several times a day. Write instructions, especially for older patients who are taking many medications, and be sure they take the instructions with them. Take time to ensure that patients understand both oral and written instructions.⁵

Give extra attention to medication instructions that are difficult to follow. For example, alendronate, used to treat osteoporosis in postmenopausal women, needs to be taken with 6 to 8 oz of water as soon as the patient wakes up. Taking it with coffee or juice significantly reduces the drug's bioavailability. The patient must then wait 30 minutes before eating or drinking anything or taking any other medication. She must remain upright for 30 minutes because lying down right after taking the drug creates a risk of severe esophageal injury.

Disorganized drug and sample storage Be careful from whom you purchase; if your office purchases medications from generic suppliers, the labeling on the containers may be unclear. Samples often come in containers that can cause confusion. Labels from the same company, especially some of the smaller suppliers, can look alike. If chlorpromazine is stored next to chlorpropamide, for example, the containers may be easily confused because of the similarity in their names. Some physicians ask a local pharmacist to sort out the offices' medication storage, especially by separating sample drug look-alikes on the shelves and keeping external products away from internal products.

Underinformed physicians One way of keeping up with the latest drug information, especially warnings about prescribing drugs to subsets of patients who should not take them, is to subscribe to e-mail updates. Two such lists are the Center for Drug Evaluation and Research (CDER) at http://www.fda.gov/cder/cdernew/listserv.html and MedWatch at http://www.fda.gov/medwatch/ , both sponsored by the FDA. To receive immediate e-mail notification of new material on the MedWatch Web site, send an e-mail to medwatch@listmanager.fda.gov. Type "subscribe" in the subject field. To receive immediate e-mail notification of new material on the CDER Web site, access http://www.fda.gov/cder/cdernew/listserv.html and follow directions.

However, label warnings and informational mailings may not be enough to prevent medication errors. A recent FDA-funded study evaluated the impact of a regulatory action by the FDA regarding contraindicated use of cisapride.⁶ This GI tract promotility agent is safe when prescribed properly but harmful if taken by patients with heart disease, patients with other conditions that could predispose to cardiac arrhythmias, or patients who are taking medications that interfere with cisapride metabolism or prolong the QT interval.⁷ In June 1998, the FDA determined that use of cisapride was contraindicated in such patients and informed practitioners through additions to the boxed warning on the label and a "Dear Health Care Professional" letter sent by the manufacturer.⁸ In the year before the warning was added, the percentages of patients in whom cisapride was contraindicated were 26%, 30%, and 60% in 3 health plans. In the year after the warning, each of those percentages decreased by only 2 percentage points. The investigators concluded that the FDA's regulatory action had no material effect on contraindicated cisapride use. The drug was withdrawn from the American market in July 2000.

WAYS TO AVOID ERRORS

The IOM report defined error as "the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim." Poor communication among physicians, staff, patients, and ancillaries such as pharmacists and transcription services is at the heart of most errors.

Keep precise medical records

Keep records thorough, detailed, readable, and accurate. Because no single, consistent method of maintaining records exists, documentation varies. Experts agree that moving to a digital environment and utilizing electronic medical records makes information more easily accessible. If data are on a paper chart, that record has to be physically available to read documentation and look up reports. Digitized records can be available at several sites simultaneously as needed. Electronic records also eliminate problems associated with unclear handwriting.

Make sure entries fully describe the patient history, physical findings, differential diagnoses, treatment plans, care rendered, advice given, and all other matters pertinent to the medical course. Clearly note allergies or drug sensitivities. Include full details about medications, treatments, procedures, laboratory work, and responses to medications or procedures. Make certain all entries are initialed or signed. To ensure legibility, dictate long entries.

When a patient returns after referral to a specialist, make sure documentation of diagnoses and therapies is readable. If a lawsuit ensues, a good record supports the course of care. Do not erase, write over, or ink out an entry explaining a course of action. Such attempts make the record less legible for your staff. In the event of a malpractice case, the patient, a third-party payer, or a plaintiff's attorney probably has a copy of the original records, and additions and deletions can seriously compromise your defense. If a mistake is found on the record, draw a single line through the incorrect entry, with the date, time, and your initials in the margin. In the event of a lawsuit, experts recommend full disclosure to the patient as well as to the insurance company.

Track data, and communicate clearly

When ordering mammography, aspiration biopsy, or other laboratory work, make sure the testing facility knows why patients are coming. Give patients adequate instructions on what is expected of them, such as overnight fasting. Make sure your office has a good tracking system so important data are not misplaced. Have a system in place to handle test results when they arrive at the office. Otherwise, patients may not be advised of results in a timely way, delaying treatment.

Patient-doctor communication is key to avoiding errors. According to a recent study by The St. Paul Companies, when a physician asks a patient, "What brings you here today?" the doctor is typically talking again within 18 seconds. Take a breath and listen while patients explain their concerns. Sit down, allow a silence, and do not place your hand on the doorknob. Such body language says, "I'm in a hurry." Building a sound relationship—nonverbal as well as verbal—is reassuring. At the end of the visit, say, "Is there anything else?" It is often then that some critical information is offered; earlier, the patient may be hesitant. Listen hard to those last few comments. If a physician-patient relationship is good, the physician is better able to handle problems that may arise, such as the need to repeat a test.

Make patients a part of their care process. Ensure that they understand their condition, the care being offered, their options, and the therapy's risks and benefits. Keep track of your patients' satisfaction level. Run surveys to find out how patients feel about you and your office.

Physicians should be using their clinical acumen to manage complex clinical problems. Routine management should be delegated to systems with consensus-driven protocols (see "Anticoagulation clinics reduce errors").

High-tech devices can help

One of the most common causes of medication errors is a failure to access basic drug information before prescribing. Prescription writers, drug-interaction devices, and computerized ordering systems can all help avoid errors. Experts suggest that every physician in private practice would benefit from a handheld point-of-care device with software specifically designed to help eliminate prescribing problems. Ideally it would be synchronized with a central computer in the hospital. Protocols are keyed in, enabling physicians to write, for example, "reteplase by protocol." The nurses and pharmacy staffers will then know exactly what to do, decreasing the likelihood of a mistake. Some handheld devices can also be programmed to correct physician orders, give access to laboratory data, and report when laboratory data is out of the normal range.*

* See "Personal digital assistants: Make them work for you," Patient Care, March 15, 2001, page 38.

At the annual meeting of the American Medical Informatics Association in Los Angeles, Calif, in November 2000, investigators from Brigham and Women's Hospital in Boston reported that they had surveyed 870 users of a handheld clinical drug reference guide (ePocrates qRx) in March 2000.⁹ Half the physicians responded that the device helped them avoid 1 or more adverse drug events per week. More than 90% of respondents reported that it took them 20 seconds or less to find information they needed, and 80% said using the device improved their drug knowledge and their ability to educate patients.

Reporting mandates

The trend away from secrecy and blame and toward a culture of openness in revealing errors before they do real harm has a downside. Documented errors can become discoverable evidence in a malpractice suit. While a systems approach to avoiding errors should decrease the number of malpractice suits, the process of uncovering mistakes could provide admissible court evidence in the event of a suit.

Policy makers disagree about whether reporting should be voluntary or mandatory. The IOM report called for a nationwide mandatory but anonymous reporting system for adverse events that result in death or serious harm. New York and 17 other states already have mandatory systems for reporting errors. The National Patient Safety Foundation, established by the American Medical Association in 1997, and the American Association of Health Plans favor a limited mandatory reporting system. Others disagree: Michael R. Cohen, RPh, MS, a consultant for this article, says that existing compulsory reporting systems have proven to be inherently punitive in nature and have suppressed open reporting and discussion of errors. Under such systems, reporters tend to reveal only the information that must be given. Opponents of mandatory systems say that required reporting has reduced error rates and that such mandates have the perverse result of hiding errors.

To report a medication error or to receive further information, call the USP Medication Errors Reporting Program at (800) 23-ERROR ([800] 233-7767).

Patient Care acknowledges the assistance of Joan H. Bristow, RN, MA, Vice President, Risk Management, The Doctors Company, Napa, Calif, http://www.thedoctors.com ; and Pam Lockowitz, RN, MS, Senior Vice President, Health Care Risk Management, The St. Paul Companies, St. Paul, Minn, http://www.stpaul.com , in preparing this article.

REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a Safer Health System. Institute of Medicine Report. Washington, DC: National Academy Press; 1999. Available at: http://bob.nap.edu/html/to_err_is_human . Accessed February 2, 2001.

2. McDonald CJ, Weiner M, Hui SL. Deaths due to medical errors are exaggerated in Institute of Medicine report. JAMA. 2000;284:93-94.

3. Leape LL. Institute of Medicine medical error figures are not exaggerated. JAMA. 2000;284:95-97.

4. US Pharmacopeia summary of the 1999 information submitted to MedMARx, a national database for hospital medication error reporting. Rockville, Md: US Pharmacopeia; 2000. Available at http://www.usp.org/medmarx . Accessed February 23, 2001.

5. Hanchak NA, Patel MB, Berlin JA, et al. Patient misunderstanding of dosing instructions. J Gen Intern Med. 1996;11:325-328.

6. Smalley W, Shatin D, Wysowski DK, et al. Contraindicated use of cisapride: Impact of Food and Drug Administration regulatory action. JAMA. 2000;284:3036-3039.

7. Piquette RK. Torsade de pointes induced by cisapride/clarithromycin interaction. Ann Pharmacother. 1999;33:22-26.

8. Klausner MA. Dear health care professional letter. Titusville, NJ: Janssen Pharmaceutical Research Foundation; June 26, 1998. Available at: http://www.fda.gov/medwatch/safety/1998/hisman.htm . Accessed April 16, 2001.

9. Rothschild JM, Lee TH, Horsky J. Survey of physicians' experience using a handheld drug reference guide. Paper presented at: Annual meeting of the American Medical Informatics Association; November 2000; Los Angeles, Calif.

SUGGESTED READING

Bates DW, Gawande AA. Error in medicine: What have we learned? [editorial]. Ann Intern Med. 2000;132:763-767.

Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277:312-317.

Vitola J, Vukamovic J, Roden DM. Cisapride-induced torsades de pointes. J Cardiovasc Electrophysiol. 1998;9:1109-1113.

Weingart SN, Ship AN, Aronson MD. Confidential clinician-reported surveillance of adverse events among medical inpatients. J Gen Intern Med. 2000;15:470-477.

Zeroing in on medication errors [editorial]. Lancet. 1997;349:369.

ARTICLE CONSULTANTS

MICHAEL R. COHEN, RPh, MS, President, Institute for Safe Medication Practices, Huntingdon Valley, Pa.

ALLAN FRANKEL, MD, Director, Patient Safety, Partner HealthCare System, Boston; and an anesthesiologist, Newton-Wellesley Hospital, Newton, Mass.

EUGENE S. OGROD, MD, JD, Past President, California Medical Association; founder, Sutter Medical Group, Sacramento, Calif; and a member of the Patient Care Subspecialist Advisory Board.

Written by Dorothy L. Pennachio based on individual interviews with the article consultants.

Strategies to tackle outpatient errors

Tracking test results, referrals and even no-shows can help keep you out of trouble

From the June ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Tips to reduce paper prescription errors in your practice
Resources to help reduce errors

PHILADELPHIA—A chest X-ray shows a suspicious lesion, but it gets filed in the patient's record without any follow-up. At the patient's next visit, you see the X-ray, notice the lesion, order a workup and find out the patient is fine. Have you made an error?

Some physicians would say no, because the patient suffered no harm. But Craig R. Keenan, ACP-ASIM Member, primary care residency program director and assistant clinical professor at University of California, Davis, would strongly disagree.

"Yes, it's a huge error, because you're letting test results slip through the cracks in your practice," said Dr. Keenan, one of three physicians who gave an Annual Session presentation on preventing outpatient errors. "Even if you were fortunate with that one patient, your current system could be delaying needed care."

Dr. Keenan notes that near misses are a warning that your practice systems need to be overhauled.

Such near misses are a clear warning, Dr. Keenan pointed out, that your practice systems could be a hazard to patients. Many outpatient errors are preventable, he said-and are often heralded by repeated near misses that physicians can't afford to ignore.

While much of the discussion about patient safety has focused on medical errors in hospitals, much less has been written about errors in the outpatient setting. But that's where many physicians need all the help they can get.

"Most of us in primary care don't have the computer-based safeguards that many hospital physicians do," said panelist Kwabena O.M. Adubofour, FACP, medical director of Fifth Street Medical Center in Stockton, Calif. "We need concrete approaches to reducing errors because we can't rely on anyone else."

Panelists noted that in the last two decades, outpatient practices have seen their patient load—and the potential for mistakes—rise dramatically. Dr. Adubofour pointed out that between 1983 and 1999, the number of outpatient visits jumped 75%, while inpatient days fell by more than 20%.

Today's office-based physicians run a particular risk of medication errors, which are now the second leading cause of malpractice claims. (Failure to diagnose claims are still more frequent.) The number of drugs on the market has jumped 500% in the past decade, Dr. Adubofour said, while 75% of all primary care office visits are associated with initiating or continuing some form of drug therapy.

While some errors may be just bad mistakes, most can be traced to bad management decisions and poorly designed systems. Dr. Adubofour and his colleagues outlined the major types of errors that occur in office-based settings and offered tips to help you avoid them in your practice.

• Abnormal test results. If your practice doesn't routinely follow up on abnormal labs, X-rays and other test results, you're making a potentially deadly mistake. Implement a system that tracks the date you ordered a test, when you received the results and the date you notified the patient.

  While your system may be as simple as keeping a test logbook, Dr. Keenan suggested that you put one staff member in charge of your tracking system, and adopt a practice-wide policy that no test results get filed in charts until you sign off on them. He also said that you should notify all patients of test results.

  "The old standby mindset of 'if it's normal, I won't call you' is dangerous," he said. "It can let suspicious results slip by."

• Adverse drug reactions. Dr. Adubofour pointed out that many recently approved drugs have been tested on only 2,500 to 5,000 patients in initial clinical trials. As a result, he said, it's essential to track adverse events that often don't become apparent until drugs have been out on the market.

  "Primary care physicians have to become more aware of the adverse drug events associated with drugs they commonly use," Dr. Adubofour said. "A medication error takes place when you continue to prescribe a drug to a patient who's manifesting an adverse drug reaction."

  He quickly added, however, that physicians also need to monitor many established medications. ACE inhibitors, for example, can induce hyperkalemia in some patients, an event you need to track. And if you prescribe long-term glucocorticoids—which can cause osteoporosis and a host of other complications—you may want to consider obtaining baseline DEXA scan data. You may also need to monitor for diabetes mellitus and hypertension with long-term glucocorticoid use.

  "It's an error to not inform patients ahead of time about potential side effects from chronic use of certain medications," he explained. "It's also an error to continue to prescribe the drug without monitoring for those adverse effects."

  Any drug that requires monitoring poses a high risk of error, including anti-seizure medications, digoxin, insulin, oral hypoglycemic agents, thiazolidinediones and warfarin. And, Dr. Adubofour pointed out, "if you're going to prescribe a drug that's been on the market for two years or less, make sure you watch that patient more closely for any adverse events."

  In order to reduce their malpractice risk, some physicians are even beginning to draw up contracts with patients who take drugs for chronic conditions. They then have on record patients' acknowledgment that they've been informed about the potential risks of long-term drug use.

  Dr. Keenan recommended setting up a tracking system that tells you when patients need to be seen and tested. He keeps a monthly calendar on his desk, with daily notations of when patients are supposed to get their lab work done.

  "We check it every morning," he said. "If two days go by and we haven't seen that patient's results, we get on the phone. It takes a lot of vigilance, but it works."

  Another simple safeguard: Don't issue automatic refills of medications that require monitoring, but give patients refills only after they've been tested. And make time to read package inserts and medication warnings, Dr. Adubofour said. Studies have shown that less than 15% of physicians comply with FDA warning letters that recommended testing liver enzymes in patients being treated with troglitazone (Rezulin).

• No-shows. Put a system in place to contact no-shows, and take the time to look through all missed- or canceled-appointment charts to see if urgent rescheduling is required.

  "A skin biopsy result showing melanoma can't wait three months, but it can easily be lost in the shuffle when the patient misses or cancels an appointment," Dr. Keenan said. Document all contacts—or attempted ones—with the patient, and make every reasonable effort to follow up.

  "Even if it's the patient who's in error, the burden is on the physician—and that's not just one phone call," he added. "In my practice, I've sent patients certified letters many times."

• Referrals. Set up another tracking system to note the date of a referral appointment, if the patient went and when you received the consultant's report. While you should track all referrals, flag those that are urgent or crucial.

  Also be sure to talk to consultants. Errors often occur during shifts between inpatient and outpatient settings, or when care is divided between primary care physicians and specialists. Dr. Adubofour recalled one cardiologist who assumed a referred congestive heart failure patient hadn't received diuretics or potassium supplements. As a result, he prescribed the same medications the patient was already taking under Dr. Adubofour's direction, and unknowingly doubled the patient's doses.

  "By the time I saw her," he said, "she was as dry as a bone." When you see patients after a referral, review with them any medications the specialist prescribed.

  Also be sure to establish communication protocols with covering physicians and hospitalists. You should talk to hospitalists when patients are admitted and discharged, and set up before-and-after communications with covering physicians as well.

• Failure to diagnose. This error is particularly prevalent in cancer patients, although failure-to-diagnose errors also occur with fractures, myocardial infarctions and infections.

  Frequently, diagnosis failures are related to other errors of omission, like letting abnormal test results be filed without follow-up. But they can also result from false assumptions.

  "We often trivialize a patient's concerns about a breast mass, particularly if she's younger, or we assume that rectal bleeding must be hemorrhoids," said Ashok V. Daftary, FACP, assistant medical director of Sutter-Gould Medical Group in Stockton, Calif.

  Instead, suspect cancer first, and rely on objective evidence instead of assumptions, he said. Follow up on complaints even when tests are negative. Mammograms, for example, can come back negative even when lesions are present, Dr. Daftary said.

• Vaccines and maintenance procedures. If you fail to keep on top of screening and other maintenance procedures, you may be inducing an error by jeopardizing patients' health and failing to make a timely diagnosis.

  Some studies indicate, Dr. Daftary said, that less than 5% of eligible patients are immunized against pneumonia, less than 30% receive annual breast cancer screenings, less than 13% get annual fecal occult blood test screenings and less than 34% have their lipids checked.

  Dr. Keenan recommended establishing a reminder system to monitor patients' health care maintenance. Computerized reminders can be helpful, he said, or you can keep a summary sheet for easy access at the front of patients' charts to check during each visit.

  "A big problem is that we run out of time and can't address all those needs in the last 20 seconds of the visit," said Dr. Keenan. "But talk about at least one procedure every time the patient comes in."

• Patient education. Patients and their families can be your strongest allies in the fight against errors, panelists said. If they understand what procedures or tests need to be done or what medications they should take, they often pick up errors or omissions. Discuss all therapeutic and medication options with them, and document informed consent.

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Tips to reduce paper prescription errors in your practice

When it comes to errors, medication mistakes are a hot spot for all physicians, but particularly for internists and other generalists. Drug errors are the second-leading cause of malpractice litigation, and internists and family physicians are involved in nearly half of all medication error claims.

One obvious way to reduce prescribing errors is to issue scripts using an electronic medical record or handheld computer. Studies have found that electronic prescribing reduces inpatient medication errors by 55%, said Craig R. Keenan, MD, assistant clinical professor of medicine at University of California, Davis.

Because e-prescribing has yet to catch on with most physicians, however, handwritten prescriptions are still a fact of life. Dr. Keenan offered the following tips to make your prescriptions as safe as possible:

• Use printing, not cursive, and write legibly.
• Note the purpose of the drug, such as "for high blood pressure," on each prescription. Notations help educate patients and allow pharmacists to catch mistakes.
• Always use metric weights, not grains. They are too easy to confuse with grams.
• Write out "units" instead of using "U." That abbreviation is often mistaken for a zero—and can lead to massive overdoses.
• Put a leading zero before the decimal point if the amount being prescribed is less than one ("0.5"). This helps pharmacists recognize the decimal point. Never use a trailing zero after the decimal point ("5.0"). The decimal point is too easy to miss and can result in an overdose.
• Use English directions, not Latin. (Specify "daily" instead of "qd.")
• Give specific directions for use instead of "use as directed," and specify the number of refills.

If you or a nurse calls in a prescription, always spell the name of the drug and avoid abbreviations. Say each numeral of dosage amounts, such as "five-zero milligrams" for 50 mg, and have the pharmacist read back the entire prescription. Be sure to document the prescription in the patient's chart.

Keep an up-to-date medication and allergy list for patients in their chart, and be sure to ask patients about any over-the-counter or herbal medications. If patients can't remember the names of all their medicines, have them do "brown-bag rounds" and bring in every vial or bottle of medication they use.

Pay particular attention to prescriptions when patients are discharged from the hospital. Chances are they're bringing home new medications that you should check against drugs they're already taking. Give patients written instructions at discharge about medications, and have your office contact their outpatient pharmacy after discharge to notify them of any medication changes.

Avoid what Dr. Keenan called "the prescription cascade" and make sure that new symptoms aren't a side effect of a drug patients are already taking. And let patients know why they're being given a drug, what it is and how often they should take it. That helps them be more vigilant against errors that can occur at the pharmacy.

Finally, be particularly cautious when prescribing medications for elderly patients. "Their lower body fat and slower metabolism and elimination means they may need lower doses," Dr. Keenan said. "Start low and go slow."

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Resources to help reduce errors

• The College offers online tips and information on patient safety initiatives. Resources include a weekly safety tip and pointers to help reduce medical errors. For more information, see www.acponline.org/ptsafety/index.html.

• Point-of-care resources can help with diagnosis and management. They also help physicians avoid relying so heavily on memory, which experts say is key to preventing all kinds of errors. The College recently debuted its Physicians' Information and Education Resource (PIER), an electronic point-of-care service that is free to College members. Go to http://pier.acponline.org and use your College ID number for access.

• The FDA's MedWatch Safety Information and Adverse Event Reporting Program lets you report adverse medication events and get up-to-date information about medication safety concerns. You can also sign up for automatic e-mail alerts. Go to www.fda.gov/medwatch/ or call 800-332-1088.

• The Institute for Safe Medication Practices sends out biweekly alerts via fax or e-mail on medication and device errors. For more information, see www.ismp.org/Pages/Newsletter.htm.

• The Massachusetts Coalition for the Prevention of Medical Errors publishes a handbook for patients, "Your Role in Safe Medication Use." It can be found online at www.mhalink.org/publications/docs/consumerguide.pdf.

• This year, the California Academy of Family Physicians published a monograph on outpatient errors called "Diagnosing and Treating Medical Errors in Family Practice." It is available online at www.familydocs.org/PDFs/MonographMedErrors.pdf or can be ordered for free by calling 415-345-8667.

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