16 Rx safeguards that also safeguard you

Medication errors can be prevented if you follow these commonsense tips.

By Dorothy L. Pennachio
Senior Editor

Everyone cringes when they hear about a patient who was injured or died because he received 10 times the proper medication dosage when a decimal point was placed incorrectly or misread. Or when a patient is given the wrong drug because it sounds like another medicine and the pharmacist didn't properly decipher the doctor's handwriting.

Those medication errors can be easily avoided if physicians and other health care professionals would rigorously follow well-established safety guidelines they're probably already familiar with.

That's why the California Medical Association, working with three professional liability insurers, mailed out "Safe Medication Principles" to 50,000 physicians in that state last year. It's also why Medical Economics has decided to give them even wider publication here.

"Most practitioners already follow basic principles similar to these," says Susan L. Penney, legal counsel for the CMA, "but we thought it would give the guidelines extra clout if we collaborated and distributed a definitive list anew under the aegis of the three insurers plus the CMA."

Project SafeCare worked with risk managers for the companies to develop the common guidelines. The insurers involved are Medical Insurance Exchange of California, NORCAL Mutual Insurance, and The SCPIE Cos.

"We encourage physicians to contact their insurers with any questions or for recommended forms," says Penney.

1. Familiarity with the medications you prescribe helps avoid uncertain results.

Lack of familiarity is a significant factor in prescribing errors. Understand the indications, contraindications, side effects, and appropriate dosage of all medications you prescribe, particularly those for pediatric and elderly patients.

2. An inventory of medications reduces surprise drug interactions.

Ask patients what medications other physicians have prescribed. Also ask about use of over-the-counter preparations, complementary medicine remedies, and alcohol and recreational drug use. Tell patients who don't know what they take to bring all their medications and other preparations to the next office visit. Time spent eliciting an accurate medication history is time saved treating adverse drug reactions.

3. Indications on prescriptions prevent dispensing errors.

Write on scripts the condition for which the medication is prescribed.

4. A detailed allergy history limits the risk of treatment failure.

Ask patients about allergies to medications, foods, or other substances. Document reported allergies on a brightly colored sticker on the cover of each patient's chart. (Write "NKDA" to indicate "no known drug allergy.") Update this information regularly. Be alert to unusual allergic manifestations.

5. Legibility reduces error.

Print all prescriptions. Encourage your staff to verify orders if they're unsure about what you wrote.

6. Clear abbreviations avoid confusion.

Spell out abbreviations for directions. (See the table.) Avoid inappropriate, "innovative," and nonstandard abbreviations.

7. Misplaced decimal points lead to dosage errors.

When it comes to zeroes, "always lead, never trail." When writing dosage amounts on prescriptions, use a leading zero before a decimal point of a fractional number (0.5 mg); don't use a trailing zero after whole numbers (write "5 mg," not "5.0 mg").

8. Writing out numbers prevents alterations.

To prevent alterations on prescriptions for controlled substances, write out the amount to be dispensed (write "thirty," rather than "30.")

9. Documenting orders and refills tracks appropriate use.

To facilitate documentation, attach a dedicated medication control record to the inside cover of each patient's chart. Include the name of the drug, the dose, the amount, indications, and directions. Avoid vague and ambiguous orders such as "Refill meds." (Contact your liability insurer for a recommended medication control form.)

10. Informed patients follow instructions.

Dispense written information about drugs in plain language to advise patients (a) the name of the drug and what it is for; (b) dose and frequency; (c) precautions and contraindications; (d) what to do if a dose is missed; (e) what potentially serious side effects the patient should report to the physician; and (f) the mild or transitory side effects that need not be reported to the physician unless they persist. Document that this information was dispensed and make sure patients take the document with them when they leave the examination room.

11. Duplicate treatment doubles your risk.

Don't write a prescription for a condition another physician is treating, unless you communicate with that physician and reach agreement about which of you will provide future prescriptions and refills. Document your discussion.

12. Informing colleagues about on-call prescriptions promotes continuity of care.

Develop an understanding with your on-call colleagues about prescription and refill limits. When on call, provide minimum refills. Inform colleagues when you have prescribed or refilled a medication for their patients.

13. A good faith exam protects patients and physicians.

A physical exam prior to prescribing is the standard of care nationwide.

14. Prescribing only for conditions you usually treat reduces liability.

Don't prescribe medications solely as a convenience to patients or for conditions you do not ordinarily treat. Refer patients to their treating physician or another appropriate physician.

15. Monitoring adherence and efficacy ensures appropriate use.

Ask and document if patients are taking their medications as prescribed. Ask patients how they are taking their medications. Before ordering refills, monitor for unexpected effects and document why the drug is still appropriate. Efficacy may need to be determined by lab studies.

16. Safeguarding prescriptive authority protects patients and physicians.

Know which licensed health care providers are allowed to prescribe in your state and what restrictions there may be on their prescriptive power. Generally, unlicensed personnel—medical assistants and other office staff—can transmit the physician's prescription or refill authorization to a pharmacy at the physician's direction.

Avoid confusion

Adapted with permission from California Medical Association, San Francisco; Medical Insurance Exchange of California, Oakland; NORCAL Mutual Insurance Company, San Francisco; and The SCPIE Companies, Los Angeles. The principles are provided as risk management advice. They do not constitute a legal opinion, are not a substitute for legal advice, and are not intended to determine the standard of care. The principles presented should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of the individual patient circumstances.

 

Dorothy Pennachio. 16 Rx safeguards that also safeguard you. Medical Economics 2003;7:99.