Medication errors orders/prescription

It was reported by the Institute for Safe Medication Practices (ISMP) in 2000 that fewer than 5 percent of physicians were writing prescriptions electronically. In a 2000 white paper entitled, A Call to Action Eliminate Handwritten Prescriptions within 3 Years, ISMP recommended the use of electronic prescribing by clinician order entry to reduce medication errors (ISMP, 2000). CPOE can help to reduce errors in the delivery and transcribing of orders to the pharmacy where the orders are filled. Order management can be used to control inventory and alert pharmacy staff (and even the patient) of the status of a prescription. For example, some national chain pharmacies have the capability of alerting the patient by phone or e-mail if a prescription is ready or if other action needs to be taken before the prescription can be picked up. The system should also be able to report results, such as the number of prescriptions filled, the revenue generated over a specified time, and medication error reports. 

Abbreviations and dose expressions cause medication errors. The handwritten or printed u intended to abbreviate unit can easily be misinterpreted as a zero, causing a 10-fold overdose. Decimal points can be difficult to read on prescriptions or orders, causing a 10-fold dose error. Decimals less than 1 should always be preceded by a zero (use 0.2, not. 2) and a whole number should not be followed by a zero (use 2, not 2.0). The Institute for Safe Medicafion Practices (ISMP) has additional recommendations on abbreviations and dose expressions (Table 16.6). ... 

Source From NCC MERP council recommendations to reduce medication errors associated with verbal medication orders and prescriptions, adopted February 20, 2001. 

Gordon, B.M. Making the Formulary Safe General Strategies for Reducing Risks. ASHP Medication Use Safety Learning Community, Baltimore, June 2002. NCC MERP council recommendations to reduce medication errors associated with verbal medication orders and prescriptions, adopted February 20, 2001. Available at www.nccmerp.org/council2001-02-20.html, accessed January 9, 2004. 

Canada) from summer of 2000 emergency department Chart review of patients treated in emergency department Sample 1532 charts = no. of patients No. of medication orders = 1678 potential errors 10% of patients subjected to medication errors (10.1 % with prescription errors, 3.9% with drug administration errors)... 

Prescriber Order-Entry Module Common dosage order database of standardized inpatient and outpatient medication orders, ready for integration into providers order-entry or prescription-writing systems helps prevent prescribing errors. 

When pharmacists and technicians interpret prescriptions and medication orders, newly marketed drugs are a particular problem. Staff members are not as familiar with names of the drugs, and they tend to misinterpret them as older drugs. It is important that up-to-date education on all new medications is provided to the pharmacy staff, including any potential for error that may exist with these new products. In the ambulatory care setting, physicians can write both the generic and trade names legibly on the prescription, and they can add the intended purpose of the medication to further alert pharmacy staff to the correct medication name. 

A label and/or a medication profile is printed. A copy of the original prescription or medication order continues to accompany the label or medication profile while the order is filled. Orders never should be filled solely on the basis of what appears on the label or medication profile because the computer entry may have been in error. 

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