Prescription Errors the Whole Point

Prescription Errors

The whole point of going to a healthcare provider is to get better, not become more ill or even die because someone misread a medication prescription. Unfortunately, that is too often the case. According to the Institute of Medicine of the National Academies, over 7,000 deaths occur a year due to medication errors. These errors can happen anywhere in the medication-use system, from prescribing to administering a drug in a variety of settings, such as hospitals, outpatient clinics, nursing homes and homecare services. As a result, in 2006 the U.S. Food and Drug Administration launched a nationwide health professional education campaign in order to reduce the number of common but preventable sources of medication mistakes caused by using unclear medical abbreviations. This announcement followed several years later after a similar statement by the Institute for Safe Medication Practices, which has been advocating for error-free prescriptions for at least 25 years. It appears that even more can be done to improve this situation, given the technology available.

Eliminating abbreviations is not a new suggestion. Many other organizations, including the Institute of Medicine, American Society of Health-System Pharmacists, Food and Drug Administration, National Coordinating Council for Medication Error Reporting and Prevention, and American Hospital Association, have long warned that the use of inappropriate abbreviations may lead to confusion and communication failures. Why it took so long for the FDA to push these changes is a good question.

Some abbreviations are acceptable, because they do not have major ramifications if read improperly, but a number of abbreviations can seriously affect the well-being of the patient if misunderstood. Some of these deemed as unsafe include: (1) U. For units, 2) µg for microgram, (3) TIW for three times a week, (4) the degree symbol for hour, (5) trailing zeros after a decimal point, and (6) the lack of leading zeros before a decimal point.

Now that these standards are in place, communication must take place in order to introduce, communicate and reinforce this need as often as possible. Just letting healthcare providers know one time, is not enough. There should be reminders on all materials that are prescription related. In addition, the words that are most problematic need to be very visible on all prescription pads. Officials from Kaiser Permanente Santa Teresa Medical Center, for example, have retrained staff on the importance of adhering to the "Five Rights of Medication Administration" -- right dose, right medication, right time, right patient, right administration (oral, intravenous, injection, Sullivan, 2005).

Passing these standards also led to a number of "safety awards" being handed out by healthcare institutions across the country. Proponents say that this emphasis is improving this situation; opponents say that it is just "window dressing" and gives hospitals another way for positive PR. For example, Arthur Levin, director of the New York-based Center for Medical Consumers, a not-for-profit patient-advocacy group says, "My gut feeling tells me that there's been little real progress in patient safety. All these awards are a way for a large organization to say, 'We're on board this safety movement.' This is easy and cheap, and it makes everybody look concerned. The awards are nice, but is this really dealing with this enormous problem effectively? The answer is no" (Romano, 2002)

There are other prescription errors as well, and the abbreviation recommendations only cover one of them. In a study by Shah, Aslam and Avery (2001) of approximately 38,000 prescriptions by 23 doctors, there were a number of errors including: 715 or 25% no directions; 510 or 18% prescribed item not mentioned (usually on repeat prescription); 321 or 11%, directions incomplete, illegible or written "as directed"; 306 or 11%, more than one month's supply given on separate repeat prescriptions without patients request; 260 or 9%, strength missing where a product existed in various strengths, and no guidance available in the BNF; 8% or 229, the prescribed quantity was not clearly written, missing or too large; and 5% or 132, prescriber's signature missing. Another 100 errors were due to prescribing medicines no longer available, incorrect medicine because handwriting, no date or wrong strength.

Given that this is the digital age, it seems that prescriptions can be easily "written" by computer or some form of electronics, and indeed that is the case. Preece, Ashford and Hunt, as early as 1984, wrote a report noting that the computer was an ideal data base for minimizing errors in subscriptions. Presently, of course, there are many handheld digital tools that can be used for this purpose, which handle problems with abbreviations, misspellings, lack of information and the like. In fact, recent studies show that although it is a change in mindset, especially for geriatric patients, e-scribes have a positive response with patients and significantly improve the amount of errors.