.. .

.' .'

KEVIN DOHERTY, PharmD .

ALISSA SEGAL, PharmD .
PATRICK G. McKINNEY, MDt
University of New Mexico

.... -. ..
..~."... :. ".
. . .'
.
-: .

4'if...).."...

.

e 5 0 0 esc I r ors:

.' . .
.
.
1 S on e 1 s

.' I
. . . '. .
3 .5
vention .. ADEs include
ABSTRACT:Numerous factors contribute nonprevent-
Dr Doherty is a
clinical pharmacist
to the medication errors that kill up to 0

able side effects of medications. such

in the 98,000 patients each year. Unnecessarily as bradycardia associated with r3-
department high dosages can result in increased side blocker use. Ameliorable effects are
,
I of pharmaceutical effects with only a small therap~~tic ben those in which severity or duration
I
I
services at the efit, especially in elderly patients. Lack can
University of New
of patient information such as a history
Mexico Health be significantly reduced with prompt i
Sciences Center of allergies or adverse drug reactions is recognition and appropriate manage- 1
in Albuquerque,

mentor; Preventable ADEs are those !

where Dr Segal another cause of error and injury. Com that can be avoided entirelv- for ex-
. .
is associate profes munication faUures include the use of ample, by awareness that a patient is I
sor of pharmacy ambiguous abbreviations, misinterpreta allergic to a specific antibiotic. Arne
. practice and assis

tant professor of
tion of verbal orders, and lack of timely liorable and preventable ADEs are ex
family and commu- response to a patient's medication-related amples of medication errors associat- I
.
nitv medicine.
~
symptoms. Dosing errors are (ommon in ed with harm. I

I
. .
Dr Mchinnev- was children because of variability in dosage A recent ambulatorv care study
associate professor expressions in drug references. Remedies found that 259b of 661 respondents re- I
of emergency
. . ,
rnedi
for prescribing errors are described in ported an ADE.-) Thirty-nine percent of
I
cine and pharmacy" detail here. these events were ameliorable or pre
I
I at the university

ventable; of this number. 69i> were seri
and medical direc- ous." A study of inpatients found that i
. ': ~.. "

tor of the New Medication errors are a significant 4.WEs occurred at a rate of 605 per 100 i
admissions. Forty-two percent were ei- I
Mexico Poison and
Drug Information cause of injury and expense. An
C enter when this Insti tute of Medicine report ther life-threatening or serious: nearly I
paper was written. estimated that between 44.000 and half of these events were judged pre- ;
veritable.' In both of these' studies. !.

[Deceased. 98.000 persons die

in US hospitals annually as a result of ,
these errors.' This report fueled dra most preventable events occurred in I
II
..
. .
. ."
matic interest in health care reform, in the prescribing stage of the drug treat- I,

c luding measures to reduce ment process.

. .)

I
medica- Numerous factors contribute to I
,

tion errors.-
A medication error is a pre
.. ventable event that could result in in- I
appropriate therapy or harm to a pa
tient 3 Although errors occur frequent
medication errors. Here we focus on t
preventable ADEs that occur in the
drug-prescribing stage. and we de
scribe strategies that may avert mis- ,

ly during various steps in the drug calculation. miscommunication and I i

I
treatment process (ie. prescribing, in mi smanagement. I

..
terpreting. clispensing, and administer Ii
ing). they infrequently lead to harm. ~ LACK (). DRUG
As a result. investigation has focused KNOWLEDGE II
. '.
wvvw.Consultantlive.com

'.
 on result in drug event t.ADE) is an injury from Errors often arise from a lack of I
errors harm. a drug-related inter .. knowledge about drugs, including in- I
that An dications and contraindications, ap- !
adverse
FEBRUARY':004 =: CONSULTANT 173
, "

,
" "

,

"

.
. ..
,

the 10 Most
COIIImon
Prescribing
Errors:
Tips on
Avoiding
the
Pitfalls

,.
'.. .~.
,
. .. ..',
.

, ' propriate doses, maximum dosages, when metformin is prescribed for LACK OF PATIENT
routes, and drug-drug interactions. women whose serum creatinine INFORMAnON
Indication errors. These include level exceeds 1.4 mg/ dL (1.5 mg/ Inadequate records and
underuse, overuse, and misuse." Un dL for men). The risk of lactic

incorrect reporting of allergies and

deruse is the failure to provide a med acidosis in drug reac tions are significant
ical intervention when it is likely to creases dramatically, and death sources of pre scribing errors.
produce a favorable outcome," An ex occa- '" Inadequate records. In one
ample is the failure to prescribe an sionally ensues. I I study, lack of information about hospi
an giotensin-converting enzyme Dosing errors. These can talized patients was the second leading
inhibi tor or angiotensin II receptor occur cause of prescribing errors that result
" ..,'
, '
,,' , blocker to prevent progression of I in elderly patients at the initiation of ed in AD Es. 1:? Such errors frequently
diabetic nephropathy in a patient with therapy. For example, hydrochloro occur in the ambulatory care setting
. - diabetes and microalbuminuria. thiazide is sometimes started at a
. .
as well. In another report. discrepan
dosage of 25 or 50 mg/ d, even cies between medications indicated in
Overuse occurs with though outpatient medical records and those
unneces sary treatment: for 6.25 mg/d is often effective.'?" When actually taken by patients occurred
example, when a broad-spectrum therapy is not gradually titrated in
antibiotic' (such as up ward and monitored, ADEs such
as orthostatic hypotension are
more
likely to occur."!' Unnecessarily high
levofloxacin) is prescribed for dosages can result in increased 76% of cases." Another discov-
un side studv..
complicated bronchitis or is initiated for an unrecognized side effects with only a small therapeutic
pharyngitis ef fect resulting from current drug benefit. When amlodipine is pre scribed at
of probably viral origin in a thera py. For example: 20 mg/ d instead of the maximum of 10
patient with no history of smoking, .Antihypertensive agents are rng/d, a small benefit in blood pressure
recurrent infection. or. fre control is offset by a substantially increased
immunosuppression. The main risk of periph eral edema."
bacterial cause of pharyn gitis is Drug ..drug interactions. These can
, r , '.
, . group A fj-hemolytic strepto cocci, have serious consequences. Dur ing the
which remain susceptible to
,

winter, patients frequently self-treat

, '

penicillin or erythromycin." influenza and cold symp toms. Thev may

Prescrip tions for more than half of use several over-the- counter (OTe)
'" .
diagnosed cases of pharyngitis are agents that contain the same
likely unnec essary; however, the compounds: symptoms may worsen or
overprescribing toxicity may develop as a result. .
of fluoroquinolones, which increases Antibiotics are sometimes pre
resistance to this class of antibiotics,
\
scribed for patients with influenza or cold
continues unabated," symptoms without a careful re view of the
A more subtle form of overuse patient's other medica
occurs when unnecessary
treatment
, ,

"
 ered the discrepancies." records. In patients hospitalized been associated with incomplete in
the I for patient records. 16 ,

potenti Preventable errors and cardiovascular disorders, most Special care is warranted
al for ~IDEs are particularly evident pre
~t\I)Es with documentation of cardiovascular
during transitions of care, as scribing errors have been med ications. A study examining the
in
50% when patients are hospital attributed med
of ized and clinicians base to this discontinuitv ."
- rates of
ical records .of elderl~ outpatients I
treannent decisions on Likewise, in- creased I found that this class ot agents was t ;

incomplete outpatient rehospitalization have

I most yequently associated with I
quently prescribed tor patients tions. For example, quinolones ADES.l; Although these are the most I
whose such
"
high blood pressure is a result of as ciprofloxacin and levofloxacin commonly prescribed medications.
NSAID can inhibit warfarin metabolism they are, potentially dangerous. and I
Gout and in crease the anticoagulation their use must be documented. \

~
, treat mild hyperuricemia from effect and the risk of bleeding." The Maintain and update a list of drugs
thiazide diuretics. same effect can occur with for each of your patients. Peri odically ask
Parkinsonian symptoms metronidazole. azithro mycin, and patients to bring their .-

resulting especially trimethoprim medications (including vitamins.

from metoclopramide are sulfamethoxazole." Cautious sup- plements, and alternative
overtreated monitor ing is always prudent when medicines)
with prescrib
levodopa."
Misuse refers to actions that ing medications for patients taking I with them to office visits. 1~Although
result
I

in preventable complications. An ex wartann. this chore may be cumbersome, it

w

ample is prescribing amoxicillin for a Drug-drug interactions can be ultimately saves time, reduces .con- I

I patient with a history of anaphylaxis to re duced by periodically updating fusion, and builds trust. This is espe- I
penicillin." Misuse can occur when a your patients' records and reviewing cially important for patients at great "

contraindication is unrecognized, as them for self-care therapies. est risk tor medication errors those.
174 CONSULTANT = FEBRUARY2004 .. ' www.Consultantlive.com


.,

w ons ti
ho ." o

ha .Another n
ve option s
ch to fi
ro
ni the ll
c ma e
an cy d.
d wh R
co ere e
m the s
or pati e
bi ent
d a
has r
co
pre c
nd
scri h
iti
p
ha nt n
s pre g.
IS
sh scri
O
ow pti
u
n on
t
th pro
p
at file
a
qu alm
ti
est ost
e
io iden
n
ns tical
t
of ly
m
ad refl
e
he ect
d
re s
i
nc wh
c
e at
a
asi med
l
de icati
r
th ons
e
e a
c
ou pati
o
t ent
is
r
pa
taki d
tie
s
als dy g
o fou a
fre nd n
que that A
ntl pa D
. .
y tien E
lac ts is
rep o
k ort
doc ed ft
um abo e
ent utS n
tim di
ati es
on as ff
of ma i
A ny c
D ADEs u
Es. trai lt
An ned ,
cha b
am
rt e
bul
revi c
ato a
ewe
ry u
rs
car s
Dia
e e
gno
stu e
sin
ve ocia o
ry tion n
dr s si
ug bet d
ha we e
s en e
a AD ff
ple Es e
th and ct
o dru s
ra gs t
of in o
po pati w
ssi ent' at
ble s c
si reg h
de ime fo
eff n r
ect can a
s. ta r
Fo e e
rm tim f
ula e. ai
tin Co n
g mm t
ass
 ne changesin were
ss bowel associated
, habits, with nearly
fa headache, 4(fJb of the
ti mood prescribing
gu errors in one
changes,
e, study, in part
sleep
na because of
us disturbance undocu
ea s, and mented drug
, maculopap allergies.'?
vo ular About 1096to
mi rashes. 13% of
tin Undoc
prescribing
g, umented
errors
allergies,
, .
involve or
The risk of
1an dering drugs
Drug
undocumen
for patients
with known
ted ADE is
allergies to
that it can
those drugs
be repeated
(including po
and then
tentially cross-
become an
reactive
error.
agents) .19
Antibiotics
Peni- cillin, sity opioid
ampicillin, hospital analgesics
amoxicillin, and and the rate
piper acillin clinic was 300A>.21
commonly cross- found A
react,". that substantial
Conversely, drug number
adverse reactions allergies of in
to antibiotics and reported accurate

opioid analgesics, as allergy

such "rashes" reports
as nausea or attrib were also
constipation, are uted to ob served
often la beled in ~-lactam for
medical records and psychotropi
as aller gies.20.21A sulfa cs,
study of records antibioti cardiovas
at a univer- cs were cu lar
"true agents,
allergies" and
in about NSAIDs.
80% of Because
the a known
cases; allergy is
for a
contraindication that are need for
to prescribing more further
the allergenic toxic, investigat
drug and less ion.
cross-reactive effective. Always
drugs in the and confirm
same class, more the
this potential costly.22 allergy
error All history
unnecessarily ergy yourself
lim its informati with a
therapeutic on in a patient
options and chart before
can result in sig nals preserib-
the use. of the
medications .
,
I
.....
~
_,oJ
I
',"

. . ,

I
Dose I

,

.. . oro-A A
Z
,

vidarabine
cytorabine (ara-C) T
z
 !

i udine (Retrovir) !
I
d azathioprine ,

o
I
I
I
I
I ,

v ,
!
I
CPZ Compazi
I

ne I
(prochlo
rperazin
e)
chlorpro
mozl ne
,

DPT I
Demerol-Phenergan-
Thorazine di ph the ria-
pe rtu ssis-tetonus (vaccine)
I

I
I
potassium
Hel chloride (the "H/
I

hydrochloric is I

acid misinterpreted I

,
as UK")
I

H
cr

hydrocort
isone
.
.
 hydrochlor
oth
iazide
i,
,

. . HCTZ
hydrochloroth iazide
hydrocortisone (read as HCT250 mg)
,
.

I
MgS04 I I

magnesium sulfate
morphine sulfate

I
I
..I\
I
.
.
m
. ..
I
MTX , methotrexate

mitoxantrone

Nitro drip .. nitroglycerin

infusion sodium
nitroprusside infusion

Norflox norfloxacin
Norflex
I
I
lAC
.
. triamcinolone
tetracaine, adrenaline,
cocaine I
1
zi nc ..
I

morphine !
I
Adopte . . .
I

d .

from
the
Institut
e for
Safe
M.edic
ation
Practic
es.
2003.
23
"

.'. . L- ~

!
~." ,
-- ~

www
.Con
sulta
ntLiv
e.co
m

I
 , " '.

The 10 Most
COlnlllOll
E
r
r
o
r
s
:
, '

Tips on , .

Avoiding
"
the Pitfalls

, '
"
'0

. ,
.

, - ~ . ,,

Table 2 -
Abbreviation
s to avoid , ~
' .. #
, J..
, , .

, , ..

,
~~,
. ..

.
o

'
:
.

'

.
'
 Dose ,.. : . ~

,,
-" , , ,

AU M uterqu
e-each
auris ,eye)
uterq
ue
(each ear)
 .
Do not use .

abbreviation to
.".

ol d ePrematur
discontin
Us
e
,

.
"
uation of
e medicati
ons
"di
when sch
ole
(intende arg
d to e"
mean
"discharg an
e")
has d
been II

misinterp dis
co
reted as nti
II

discontin nu
ued" e"
when
followed
by a list
of drugs

,-"'9,"_._----~, - " or ...-.

II

microgra~--~-,-:-- m ".mic _..

Mistaken- ..for e rogr
!!mg".,when g, am
hondwrinen --- "
.~.","Use
 od or OD Use "dolly'
every day
Misinterpreted
as Ilright'eye"
(00, oculus

dexter
).
Result
s in
admin
istrati
on of
oral
medication
s in the
eye. .
"
, TIW or tiw 3 times a week
Mistaken for "3 times a day"
Do not use abbreviation "

I
per o The for "left
as I,OS" eye" I
can
be
mista
ken
Use " Ily"
"PO, o

qdor e Mi U "d or
QO sta s 01 , ev
U N

ke e 1 " ery
n y
as.
"
qid
",
es
pe
cial
ly if
a
per
iod
aft
er
the
" q'
or
the
ta~
1of
the
"q"
is
mi
sre
ad
as
d"oy I
qn nightfy or at
bedtime Misinterpreted as I
"qh' (every hour)
Use IInighrly" .

I , ,

q ,'Misread as every hour

h Use "nightfy"
s I
n
i
g
h
tl
y
a
t
b
e
dt
i
m
e
"

q6PM, every day at 6 PM

Misread as every 6 h
 1
Us
e
"6
PM
nig
htly
"
!
qo Misinterpr Use "every
d eted as other day"
or " qd"
Q (daily) or
O II qid"
D (4 times
'ev daily) if
ery the "0" is
poorly
oth
wriHen
er
da
y
subcutaneous The "q" has Use ,"subcur
been mistaken " or
for "every" (e IIsubcutaneo
, 1 heparin, us" \

dose ordered ""

IIsub q
'2 before
misunderstood
I
,

sc
"


subcutaneo
us
Mistaken for
"Sl" (subli
nguol)
Use
"subcut" or
I
II subcutaneous" , I
IJ or u
" Read as Use
u a zero "unit"
,
"0" or a 1I
four 1'4",
causing a
1O-fold
overdose
or greater
(4U seen
as " '

I
"40"

or ....
44") .
I
IU I'
_.
internofioncl unit
.'
Misread as "IV" .
(intravenous)
'

Use "units"
,

cc cubic ,

.~~.~I,"
, , '

centimeters Misread as .- ..
"U" (units)

" ,
 Use IIml" _ _.

_" 4
"

Mistak ys
x3 en for
d "
"3
doses
"
, , I
t

Use I'hs"
"

BT Mista I

bedtime ken I

for
UBID"
(twic
e
daily)
.
5" or lh
ss (apothec
ary)
sli
di Adapted
n from the
g Institutefor
sc Safe ~ication
Practices.
al 2003.23
e
(i
ns
uli
n)
Mi
st
ak
e
n
fo
r
U5

,

"
I
..
o

I
i
Spell
out U I .. I
slidi ng I
,
"
"

seaIe" I
I

"one
Use I
half" or
I'lh If

7 N ULTANT C FEBRUARY200.4
wvvvv. Consultantlive .com
.10 Conunon
Errors:
"

TIps on
Avoiding
the Pitfalls
" ,

in nts recent death

g. descr
of a child
A ibe from a pre
s theirscribing
that error
involved
k re a trailing
p actio
ns
at inclu
ding
the
circu
ie msta
nces
in weight units volume
units
(eg, 2 mg) 1tsp). (eg,
instead of
the
and ADE ... ..
sympthe
~.: .:
su
rr ..
ou patient
ndi
communic
ng . .
toms of Failed sourceatio
of n.
the communicat prescribing
reaction ion
before associat ed
exclud with poor
.
. ing handwriting
therape , misinter
utic preted
options verbal
. orders, and
the use of
COM abbreviation
MUNI s or
CATIO misplaced
N decimals,-
FAILU is an
RE important
 ,""wuet
t al1 ms,"
O
. a In an Strate
s
P p ambul gies to
h propria atory improve
a tely care patient-
r written study, physician
m prescri 63% of com
a ptions amelio municati
c in rable on are
i ADEs essential;
e occurr they
s ed include
c when discussin
a physici g the
n ans potential
m failed side
i to effects of
s respond newly
i to prescribe
n patient d
t s' medicati
e medic ons.
r ation- using
p related open-
r sympto ended
e
q
errors. wa ing office
ys visits, and
pre providing
scr patients
ibe
rs
mi
ght
ne
ver
anti
ci
,
'.
. :~.
The list of
Joint abbreviation
Commissio s that are
n for the unaccept
Ac able for use
creditation on
of medication
Healthcare orders.P
Organiza Tables 1, 2,
tions and 3 list
requires abbreviation
hospitals to s and
develop a , punctuation
t tion pate. for both of
h errors. Recently, these errors,
a Death or confusion you can ..
t serious in between . e the risk
jury has opium of this
h
resulted tincture (10 occurrence
a
from mg/mL of by writing
v
misinterpr mor phine) "paregoric"
e
e tations and instead of
r of each camphorate "camphorated
e of the d tincture tincture of
s abbreviati of opium opium, and
~t

u ons found (0.4 mg/mL writing doses

l in these of
t tables. morphine) to avoid
e 'This (paregoric)
d includes resulted in 2
the deaths from
i
n morphine
Tabl. 3 overdoses."
m Although
e
-
phar
d Punctuat macists
i ion anel were
c responsible
a
w . Some n to uted to
i physi explain inadequa
t cians potentia te patient
h l education
use e-
advers ." Some
e mail to
e ef
d commu clinicians
fects
u nicate are
before
c with reluctant
treatme
a their to
nt is
t discuss
patient initiate
i s. d." In
o An one
, '

n indepe
a ndent study,
l risk 18% of
factor preventa
m ble
for
a ADEs
ADEs
t in
in
e ambula
outpatie
r tory
nts is
i
the older
a
failure person
l
of the s were
s
clinicia attrib
 meantng
I
Misun Use the
Apot dersto metric
systemI
heca od or
ry misre
sym ad
bols (symb
dram
ol
for and
dr
"

am ,I
.
mi
"

.
:

sre
ad
as
"3
II

mi
ni
m
m
is
re
a
d
as
"m
L")
 > Mista Use II

an kenly reater
d used than" or
< for "less t an II
gr the i
ee oppos .
ter ite of
th what
an
was
and less than inten
ded
/ (slash s ndica Misundersto
tes
mark) e IIperi od as the
p l number
a 1 ("25
r units/l 0
a units"
t read as
e "110"
units)
s
2
d
o
s
e
s
o
r
i
Use s parate
"per" to e doses
Name,lnderol 40 mg Always 'use
letters, Misread as s ce
and Inderal 140 mg between
dose drug name,
numbe , ,
ose, and
rs unit \

run of measure
tether 1 mg
(eg, . Misread
,

Indera as' 10 mg if the Do not use

0 mg) terminal
decimal zeros

Zero point for doses

after not expressed
decimal in
point whole
(1.0) numbers
.'

No zero .5 mg 0.5 mg
before misread as 5 mg
decimal Always use zero before a
dose decimal wh
less than a
 Adapted from the Institute for Sofe
Medication Practices. 2003.23
. .- .

118 CONSULTANT C; FEBRUARY2004

www.CcnsultontLive.com
,
,

.
.. . . .

~',
.'
.

~
,
.
C
The 10 E
. .'

Tips on
Avoiding
.'
the Pitfalls

p
o
t
e
n
t
i
.
'
a
l
A
D
E
. ..
s
b
e
c
a
u
,
su r -
es e g
s n e
o
i c s
f
o e t
cn ; s
os h
n o t
m h
c w
a a
e e
y t
r v
nc e s
o r u
t
m , c
h
p e h
a
r v
t c
o i
sm o
d
ui n
e
cs c
n
he e
c
r
d a e
n
i d s s
s h u
c a
e g
r e t -
en s
a
ut t
nc r
e
wo e
l
au c
y
r o
n
- g a
s
r e n t
al i t
ni z r
t n e i
eg b
a
d u
n
. h t
" e d
e
Pl a A
r p p D
es p E
t p r s
r a o t
et p o
ai r
t e i t
mn h
ed n e
i t c
d
s s t
r
c o s
u
u f
g a
s t
t s s
e
h n p
et o
yh i
o
e n
am t r
r e c
e w
i r a
t t p r
ah r e
k e ;
i y t
no s
e
gu i f
. f
a d e
nP e c
da e t
t i
t i f
oe f v
ee patien r
u ts do n
c
t not s
o
r know .
m
a how
m O
l to p
u
i a e
n r
z n
i t
e -
c i
at e
c n
t h u d
i i l e
os a d
nr t
e q
we u
i s t
h e
l p s
l o e
n i t
hs r i
ee c o
l . o n
p" n s
Ofte
nn c s
e
un t
I s
c e
e
hE d
x '. .' ," .

R u w
aR i
a
sO t
l
"R h
d
HS
y s
oI e
s
wN -
f
a u l
r S n e
P
eE c c
C t t
yI i i
oA o v
uL n e
a s
f -
s e
e
s r
e
o o
l
c t
-
i o
'
a n
i
 iI o a a
In an
n r
ambu g
r lator e
e y care l
u study, y
p the
t r r
a a e
k t f
e e l
s e
i o c
n f t
h A e
i D d
b E
s t
i
l h
t e
POPULA .
. d
TIONS
Chil y dosed for Variability in
dren. children dosage
Drugs based on expres sions
'

.
.
are body such as "100
commonl weight mg/kg/ d in
4 Co can result ception of
mmunica in anticoagula
d
ting with nts,
i
older pa which
-
tients were
poses associated
special with a
difficulties disproport
. Visual ionately
or high rate
hearing of events,"
impairme Continuous,
nts, care ful
which warfarin
pa tients monitorin
sometim g is often
es deny, diffi
.
vided mi cult for st
A
.
' ~

doses" sunderstan individua ud

versus dings. In a l y
"100 study of clinicians
mg/kg older .
per
..

.. ,
. :

,. .
 ..
d 5 mg/kg Elder pa tient
a qid' can ly often
y cause
persons. includes
d confusion
,
Increasin combinatio
i or error," gly, ns
v . clinicians of
i Rem care for prescriptio
d edies older n, OTC,
e include patients and
d prescriber with alternative
e edu- comorbid products.
v cation, condition Approxima
" .
e standardi s, each of tely two
r zation of which thirds of
y drug might persons
6 refer ence require aged 65
,
.
h reporting several years or
older use
.

o (including medication
u tables), s.' Therapy prescription
r and whether and
s computer prescribed nonprescrip
" ized by a tion
o order physician drugs. On
r entry" or self- average,
" prescribe these
2 d by a patients
ti ncurrentl outpatients recorrunend
ac y.' Make , errors in pillboxes.
ka a patient Patients
et point to adher ence may
4i ask older accounted feel
o patients for 21% of uncomf
on about the preventabl ortable
rs OTe and e errors, if a clinician
5a alternative such as speaks loudly
n products taking the or slowly to
pd they are wrong them. Ask
r taking; dose." your hearing
e2 patients Give and visually
sO often do legible impaired
cT not written patients how
re consider instruc best to
ip these to tions and commu nicate
r
p be specify with them, or
o
td medicatio times when use
iu ns. medica pictograms to
oc www C' tions are to emphasize
nt onsultontlive. be taken. important
com
You may points. Ask
ms
wish to them to
ec
repeat back
do
important
in t that which toxicity" can
s
st c compare were occur with
Mon even I small
itori d
ru also
ct bleeding more decreases
ng in renal
io and cost-
erro throm function." I
ns effective.
rs. boembo 28 One study
. In lic Declini described
A
one events ng the failure
hi
stud in ant renal to re spond
g
h y, coagulat functio to .signs and
er 6 n is symptoms 'of
i ion
fr clinics an im- digox
I
e with in toxicity
portant nausea,
q those
u consid vomiting,
that
e occurred
eration and
n during in anorexia
c standard prescrib as a
y care ing corrunon
of found for preventabl
cli significa elderly e error. Ii
ntly patients.
ni Regular
c fewer For
events evaluation
vi example, !
in the of the
si digoxin
clinics, renal
f t FEB 200 NSULT
u
n
P
A
d
RUA 4 = ANT

c p RY CO 181
c

..
------
, ' '

------
------
------
------
----
~--~. , '

~.----
------
------
------
, , ---~
The 10
.
Errors:
"

Tips on
Avoiding
the
Pitfalls

o Drug-
drug
CLINI interactio
ns may
CAL occur
HIGH when
patients
LIGH self-
TS
prescribe n and
over ..the update a
counter list of
products drugs
or for each
alternative of your
agents, or patients.
when Periodi
medication cally
s that
ask
should
them
not he
especiall
taken
y those
togeth
with
er
multiple
(such
chronic
as a
comorbi
quinolo
d
ne and
conditio
w
arin) ns r

are to bring
their
prescri
medicati
bed.
ons
Maintai
 (including potential
vitamins, ly
supplement cross-
s, and reactive
alternativ agents).
e Convers
medicines) ely,
along on adverse
office reactions
visits. to
antibioti
o About cs and

10%to opioids,
13%of such as
prescribing nau ..
errors

involve sea or
ordering constipatio
drugs for n, are
patients often
with known labeled in
allergies to medical
those records
drugs as
(including allergies.
o Withho ..
,
'
"

lding or
9. Under
substituti JA
ng Stafford
RS..
treatment Antibiotic
based on treatment
of adults
inaccurat with sore
e allergy throat by
community
report .. primary
care
ing physicians:
unnecessa a national
survey,
rily 1989-1999.
limits j.tLlfA
2001;
therapeuti 286:1181-1186.
c options 10. Rochon PA.
Gurwitz JH.
and can Optimising drug
result in treat
ment for elderly
the use people: the
prescribing
of alter cascade.
BMf 1997;315: 1()96.
1099.
11.
Micromed
ex
Thomson
~IICRO~I
EDEX .'.\
11 rights reserved. NIICRO~IEDEX pact on patient
Healthcare Series. Vol. 118. Expires care at a
December 2003. hemodialysis
12. Leape LL Bates D\V, Cullen DJ, et ale center. Phar
Svsterns macotherapy.
analysis of adverse drug events, JrL'L4. 2003;23:231-239 .
1995;274: 1S. LaPointe
3543. Nl\Lo\.J ollis J G.
13. Bedell SE. Jabbour S, Goldberg R et ale Medication errors
Dis- in
crepancies in the use of medications: their hospitalized
extent cardiovascular
and predictors in an outpatient practice. An-h patients. Arch
Intel''' Intern Med.
;Wed. 2000;160:2129-2134. 2003: 163:14611466.
14. Manley HJ, Drayer DK :\lcClaran :\,1. et 16. Moore C.
al, Wisnivesky J.

Drug record discrepancies in art outpatient \Villiams S. ~'lcGinn

electron T.
ic medical record: frequency', type, and
potential irn
Medical of care
native errors from
medication related to
s that are discontinui
more ty
toxic, less
effective,
and more
costly.
Always
prescrib
confirm a
ing.
patient's
allergy O Discu
history ss
before potential
side
effects
 with r
patients e
when a
new c
therapy is o
initiat ... r
. ,
, ed. Such d
discussions enhance s
trust and do not
o
compromise
f
adherence.
e
[] Special l
care is d
warranted e
with the
r
documenta
l
tion of
y
cardiovasc
ular o
medica u
" tions. A t
study that p
examined a
the t
medical i
 ents an inpatient to an
outpatient setting.
found J Gen Intern
that this ~'1Jet1
class of 2003:18:646-651"
17. Curwitz JH.
agents Field TS. Harrold
LR Incidence and
was preventability of
frequently adverse drug
events among
associated older
with persons in the
ambulatory' setting.
adverse JAj'vL4. 2003;289:
drug 1107-1116 .
18. Lau HS. de
events. Boer A Beuning
KS. et at Valida
tion of pharmacy
records in drug
exposure assess.
mentJ Gin
Epidemiol.
1997:50:61%25.
19. Lesar TS.
Briceland L. Stein
D. Factors related
to errors in
medication
prescribing.
JAl.1t/A 1997;277:
312317.
20. Pilzer JD.
Burke TG. Mutnick
.i. ll. Drug allergy
h lped drug
e improve selecti
o ractions, assist
n dosing ants
, cal are
s culations light
c and hold
r schedulin copiou
e g, s
e integra
n tion
laborato
i ry
n results.
g Many
organizations
f recommend
o that
r clinicians
d have
r point-of-
u care
g drug
i informati
n on
t available.
e Personal
digital
clinic. monitor 1. Kohn LT. assessment at a
Corrigan university hospital
patients at risk 1~1.Donaldso and clinic. Am J
for ADEs t and n MS. eds, Health Syst Pnarm.
To 1996:53:297()'297
provide point-of- Err Is Human: 5. I
care sup port to Building a 21. Preston SL.
Safer Health Briceland LL Lesar
help clinicians System. Wash TS. Accuracv of
treat their pa penicillin allergy
reporting .. ..un J
tien Health SJ'St Pharm.
ts 1994:51:79-84.
22. 2003
mo National
st patient
safety
eff goals.
Joint
ecti Com
vel mission
for the.
y. Accredita
tion of
Healthcar
e Organ
R izations.
E Available
F at
E http://ww
R w.jcaho.o
E rg/
accredited-
N
organizations/
C patient -safety /
E 03+npsg/
S npsg_03.htm ..
: Accessed June 4.
2003.
23. Please don't sleep institute for Practices.
through this wake up call. Safe Medication
.: Medication
ington.
a DC:
le vailable at
m National
rt hrtp.Z/www.ism
, . p.org/
o Academy A
u Press: .
n 2000.
t
s
o
f
i
n
f
o
r
m
a
t
i
o
n
,
a
n
d
a
r
e
u
p

.
'
"

 d ambiguous 2. Manasse skilled-nursing

:.
A HR Jr. Not too facilities. Am J
.
sit perfect: hard Healtn S)St Pharm:
lessons 2002;59:436446.
uations.
Clinical and small S. Bates D\V,
pharmacis
ts in victories in Cullen DJ. Laird
outpa patient safety.. N. et al, for the
-!m J Health .-\DE Prevention
Syst Study Group.
Pharm. Incidence of
2003:60:780-i87. adverse drug
3 . American events and
Society of potential adverse
Hospital drug events:
Pharmacists. irnplica tions for
Sug
prevention. JA.t\L4_
gested
1995;27-1:29--34.
definitions and
relationships 6. Gandhi TK.
among medica Weingart 51'1,
tion Borus J. et al.
misadventures. Adverse
medication drug events in
ambulatory care ..
errors. adverse ". Eng/ J Med: 2003;
drug events.
and adverse
drug reactions
.. -lIn J J Iealth
S)'St Pnarm.
1998:55: 165-
166.
4. Flynn ~~
Barker KN.
Pepper G-\.et
at C ompari son
of methods for
detecting
medication
errors in 36
hospitals and
m d an
1 anticoagulation
s clinic with
2 usual medical
a S care:
a t
C
r 1
t 2
i c
1
c 2
l v
f
e l
s 2
e
/ 2
o
w f
a
k
e
u
p
c
a
l
l
.
h
t
r
n
l
.
A
c
c
e
s
s
e
 348: 1556-1564.
t evidence
7. Beers \IH.
Berkow Reds.
i based
The .\/erck Manual
e informat
of

n ion Geriatrics. 3rd ed.

Whitehouse
t about
Station. NJ: Merck
newResearch
c Laboratories;
drugs,
2000.
l 8. Lee TI-I .\
i
"

broader concept of
perfor medical errors" N
n m Eng[ J Med.
i medicati 2002:347:1965-1967
.
c on use
s studies.
c eval
a uate .
n overall
performa
p
nce
r the
o
1,R')
v rnN~l
i JlTANT
FFBR
d Y?004
e
anticoagulation control.
patient outcomes. and
health- I
care costs. Arch Intern .\/ed.
1998:158:1641-1647.
,
29. Schiff GD. Rucker DT.
Computerized prescrib-
I
ing: building the electronic
infrastructure for better
medication usage. JAl.l,L4.
1998;279: 1024-1029.

w
w
w.
C
o
n
s
ul
ta
nt
Li
v
e.
c
o
m