AVOIDING MEDICATION ERRORS:

SAFE PRESCRIBING PRACTICES

Several factors in prescribing practices have been identified as increasing the risk of causing a serious medication error. The National Coordinating Council for Medication Error Reporting and Prevention emphasizes that illegibility of prescriptions and medication orders has resulted in the injuries to, or deaths of patients. The following are expectations on safe prescribing practices.¹

· All orders must be legible

· Make sure patient’s name and medical record number are on the order sheet

· Include the date, time, physician signature, and physician pager number on all orders

· When possible, include the purpose of the order (e.g. for cough)

· All orders should be written in the metric system, except for therapies that use standard units (e.g. insulin, vitamins)

· Spell out “units” rather than using “U”

· Orders should be written in total dosage amount, rather than by volume or as a amount per weight (e.g. mg/kg)

· All medications should always include drug name, exact metric dose and concentration and dosage form

· A leading zero should always precede a decimal expression of less than one (e.g. 0.1 mg)

· Trailing zeros should never be used (e.g. 1.0 mg vs. 10 mg)

· Use only approved abbreviations, which may be found in the front of the formulary or on the website, http://www2.kumc.edu/pharmacy/medabbreviations.htm

· Use an order form when available (e.g. weight based heparin dosing protocol order form)

· Patient allergies should be written on the order sheet.

· Consult with pharmacist for assistance regarding questionable orders

Several studies have researched why medication errors occur. These studies have identified four phases of the order process; ordering, administration, transcription, and dispensing. Results from the studies show that errors are more likely to be caught at earlier stages of the process (e.g. ordering phase), than at later stages (e.g. administration phase).² Safe prescribing practices should decrease miscommunication and therefore the risk of medication errors.

Prepared by Antonia Zapantis, Pharm.D., Pharmacy Practice Management

3/19/02

1. Ellis WM, Improving the safety of medication orders. National Coordinating Council for Medication Error Reporting and Prevention. March 19, 1999.

2. Bates DW, Cullen DJ, Laird N, et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. JAMA 1995;264:29-34.