Monday, November 20, 2006

Medical Error | Prescription Drug Error | To Err Is Human

To err is human, but every effort must be made to reduce prescription drug error which is a common type of medical error.

There are many ways that a medication error can occur due to a prescription error.

Physician Errors:

1) Illegible handwriting causing a pharmacist to dispense the wrong drug, wrong strength of drug, wrong direction, wrong dosage or wrong quantity.

2) Legible handwriting but with wrong strength, wrong direction or wrong quantity.

3) Prescribing medication that patient is allergic to.

Pharmacist Errors:

1) Misread the name of the medication and therefore dispense the wrong medication without cross-checking with the prescribing physician.

2) Changing the strength of the medication without informing the prescribing physician and or the patient. Example: Hydrochlorthiazide(12.5 mg) was prescribed and the direction was for patient to take 1 tablet or 1 capsule a day. The pharmacist dispensed a 50 mg strength and the correct direction to take 1/2 of a tablet was printed correctly on the medication label. The patient who was so used to taking one tablet a day may or will continue to take 1 tablet a day, causing an inadvertent overdosing. This is quite a common error.

3) Guessing physician's handwriting which is illegible.

4) Do not crosscheck with physician about potential error committed by physician.

Patient Errors:

1) Do not read the direction on the label on the bottle of the medication especially when it is a refill.

2) Can not read the medication instruction due to poor eyesight or lack of proper education.

3) Unintentional over or under dosing due to forgetfulness.

4) Increasing or decreasing the dosage for whatever reason without telling the physician.

To Err Is Human! But every effort must be made to minimize prescription error. The physician, pharmacist and patient all play important roles in preventing this kind of error.

The followings are a few suggestions and should be a common practice.

1) The physician must write legibly. Writing the name of the medication in capital letters is a good idea. The strength, dosage and instruction of the medication must be accurate. When in doubt, consult the Physician Desk References(PDR) or other resource.

2) The pharmacist must verify with the ordering physician, if there is any doubt about all aspects of the accuracies of the prescription whether it's a written or a phone order.

3) The patient must read the prescription before leaving the office to spot any error and remind the physician to correct it, if any. If the prescribed medication is not familiar to you, feel free to ask whether you can be allergic to it, if you have history of allergic to certain medications.After the receipt of the prescribed medication from the pharmacist, the patient must read the all the information on the label on the bottle.

The subjects of ePrescription, high-risk medications, mail-order prescriptions and phone-order changes of medication dosage and or instruction deserve to be on another post.


md said...

There several items prohibited to be written on the order sheet at the place where I work, in order to avoid medication errors such as:

Do not write "bid" or "tid".....write... "2 times" or "3 times"

Do not write... "OS", "OD".....write... "left ear" or "right ear"

Do not write "u" when ordering insulin dosage....write "unit"

Just a few example,

There is a huge list of these in our hospital manual.

Ken Farbstein said...

An example of a pharmacist's error in dispensing a drug with a look-alike name can be found here.