Below are 7 potentially deadly prescribing errors to review gathered from information of literature, patient safety experts, and ISMP:
1.) Prescribing the wrong drug 2,3
· Erx systems can auto-populate or present drop-down menus after the first few words are typed into a search field, which may allow for a provider to inadvertently select the wrong medication. In addition, medications are available in different formulations that may make prescribing confusing
o Recommendation: become familiar with different drug modifiers, be explicit with the dosing directions and frequency when sending the prescription. Review dose and directions with the patient.
2.) Alert Madness 4,5,6
· It can be overwhelming when many alerts notify prescribers related to allergies, duplications, potential drug/drug interactions, and inappropriate doses, even when a reason for the override is requested. One study showed 93% of drug/drug interactions and drug-allergy alerts were overridden.
· Recommendation: be mindful of the alerts provided and do not override without being confident in the rationale
3.) Failure to Adjust 7,8,9
· CKD is an increasing concern in elderly people in addition to being on multiple medications to help manage comorbid conditions. A recent study identified the following meds prescribed to the elderly without evaluation of renal function: perindopril, fenofibrate, gliptins, metformin, olmesartan, and bisphosphonates
· Recommendation: monitor patient’s renal function and use Cockcroft-Gault equation to calculate CrCl or the Modification of Diet in Renal Disease (MDRD) study equation to determine GFR. Consider other types of adjustments needed depending on the disease state
4.) Phoning it in 10
· As of 2014, smartphones were being used by one third of physicians to prescribe. This can increase the convenience of prescribing, but has an effect on patient safety. Risks of transmission of infection, interference from electromagnetic radiation, breach of confidentiality, multi-tasking, and potential interruption.
· Recommendation: be cautious when using phone to prescribe and be mindful of potential mistakes
5.) Errors In, Errors Out 11
· Wrong, out-dated, or missing information can result in various errors. Patient information that is critical to prescribing include: allergies, medical history, current medication list, body weight, and laboratory data
· Recommendation: make sure the information you have is up-to-date and correct!
6.) Ambiguous Abbreviations 12,13
· Using abbreviations as well as using leading and trailing zeros when prescribing can lead to errors
Recommendation: review Joint Commission’s “Do Not Use” list
7.) More Errors
· Wrong patient- be mindful of seeing multiple patients and switching back and forth between their charts13
· Wrong dose or frequency selection-can occur more frequently with e-RX due to drop down menus. Other providers will rely heavily on a comment box to provide instructions, which can be ambiguous or confusing to the pharmacy and patient
· Errors in dose calculation
· Failures to de-prescribe- when a medication is stopped or discontinued but the patient and/or the pharmacy is not notified of this change. This can increase the risk of drug/drug interactions and adverse drug events, especially in an elderly population. 14,15,16
1. Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83:427-437.
2. Fava W, Holquist C. Delayed release vs. extended release Rxs. DrugTopics. July 23, 2007. http://drugtopics.modernmedicine.com/drug-topics/news/clinical/pharmacy/fda-safety-page-delayed-release-vs-extended-release-rxs?page=full Accessed October 30, 2015.
3. Drug name suffix confusion is a common source of error. Pennsylvania Patient Safety Advisory. 2004;1:17-18. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2004/dec1(4)/Pages/17.aspx# Accessed October 30, 2015
4. Russ AL, Zillich AJ, McManus MS, Doebbeling BN, Saleem JJ. Prescribers' interactions with medication alerts at the point of prescribing: a multi-method, in situ investigation of the human-computer interaction. Int J Med Inform. 2012;81:232-243.
5. van der Sijs H, Aarts J, Vulto A, Berg M. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc. 2006;13:138-147.
6. Coleman JJ, Hodson J, Thomas SK, Brooks HL, Ferner RE. Temporal and other factors that influence the time doctors take to prescribe using an electronic prescribing system. J Am Med Inform Assoc. 2015;22:206-212.
7. Stevens LA, Viswanathan G, Weiner DE. Chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. Adv Chronic Kidney Dis. 2010;17:293-301.
8. Khanal A, Peterson GM, Castelino RL, Jose MD. Potentially inappropriate prescribing of renally cleared drugs in elderly patients in community and aged care settings. Drugs Aging. 2015;32:391-400.
9. Lassiter J, Bennett WM, Olyaei AJ. Drug dosing in elderly patients with chronic kidney disease. Clin Geriatr Med. 2013;29:657-705.
10. Alvarez A. What tasks are physicians performing on their smartphones? Kantar Media. October 22, 2014. http://www.kantarmedia-healthcare.com/what-tasks-are-physicians-performing-on-their-smartphones Accessed October 30, 2015
11. Bokser SJ. A weighty mistake. Morbidity and Mortality Rounds on the Web. March, 2013. http://webmm.ahrq.gov/case.aspx?caseID=293. Accessed October 30, 2015
12. Abramson EL, Bates DW, Jenter C, et al. Ambulatory prescribing errors among community-based providers in two states. J Am Med Inform Assoc. 2012;19:644-648.
13. Institute for Safe Medication Practices. Oops sorry, wrong patient. ISMP Medication Safety Alert. 2011;16. https://www.ismp.org/newsletters/acutecare/articles/20110310.asp Accessed September 7, 2015.
14. Velo GP, Minuz P. Medication errors: prescribing faults and prescription errors. Br J Clin Pharmacol. 2009;67:624-628.
15. Anthierens S, Tansens A, Petrovic M, Christiaens T. Qualitative insights into general practitioners views on polypharmacy. BMC Fam Pract. 2010;11:65.
16. Farrell B, Tsang C, Raman-Wilms L, Irving H, Conklin J, Pottie K. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified delphi process. PLoS One. 2015;10:e0122246.
Source: Courtesy of Amelia (Amy) Willer, PharmD
Amelia (Amy) Willer, PharmD