How doctors can prevent prescription errors

By Naveed Saleh, MD, MS, for MDLinx
Published February 13, 2020

Key Takeaways

With more than 10,000 prescription drugs on the market and about one-third of all American adults taking five or more medications daily, there is plenty of room for potential adverse drug events. Each year, adverse drug events lead to an estimated 700,000 emergency department visits and 100,000 hospitalizations, according to the Agency for Healthcare Research and Quality. Unnervingly, most are considered preventable. 

It's no secret that electronic health records (EHRs) are time-consuming, and you might sometimes feel that you are spending precious time filling out paperwork when you can be seeing another patient. But, it’s important to remember that EHRs have helped mitigate preventable errors. Although no approach is fail-safe, following certain good practices and safety strategies can help minimize the risk of preventable errors.

Here’s a closer look at some examples of preventable medication errors and strategies to prevent them.

Examples of medication mix-ups

All of the following examples of medication mix-ups have actually occurred, with varying degrees of frequency:

Confusing name pairs. The issue of look-alike and sound-alike (LASA) medication errors becomes graver as more drugs hit the market. The health effects can range from no harm to death. A physician’s poor penmanship or a pharmacist’s inability to read a prescription can result in LASA medication errors. 

Confusion may arise due to similarities in the spelling and sound between two brand names (eg, Keppra and Kaletra), between two generic names (eg, midodrine and minoxidil), or between a brand and a generic name (eg, Hespan and heparin). For instance, the FDA has noted several instances of mix-ups between Farxiga (dapagliflozin), a drug that lowers blood glucose levels in type 2 diabetes, and Fetzima (levomilnacipran), an antidepressant. Similarities between the names include that they both begin with f and end with a, both possess three syllables, and both have seven letters. Moreover, both drugs were approved within 6 months of each other, which can further lead to conflation. 

Ambiguous course dosing. To obviate any confusion, doses should explicitly and routinely be prescribed using the “dose/kg/day for a set amount of days” format. Also, dosing by telephone order—even when repeated back—should be avoided.

Consider the following scenario: An incorrect dose of intravenous immune globulin (IVIG) was administered to a patient with myasthenia gravis after a pharmacist fielded a telephone order for IVIG 150 g for 5 days for a 75-kg patient. After cross-checking the order, the pharmacist found a reference for “total dose of 1-2 g/kg, given over 2-5 days.” However, three other pharmacists read this order as 2 g/kg/day for 2 to 5 days. The patient received one dose of 150 g on the first day. Fortunately, the mistake was caught on the second day.

Drug-drug interactions. With an increasing number of drugs introduced each year, adverse drug-drug interactions have become a rapidly growing problem. Although physicians are often alerted to potential drug-drug interactions, the sheer number of drugs out there can make it impossible to remember all of them. Therefore, it’s a good idea for physicians to reference EHR clinical decision support tools—or a resource like Micromedex—to screen drugs for potentially harmful interactions.

Precipitant drugs modify the object drug’s clinical effect, absorption, distribution, metabolism, or excretion. Examples include antibiotics and nonsteroidal anti-inflammatory drugs. Object drugs with low therapeutic indices or narrow therapeutic ranges are particularly susceptible to the effects of precipitant drugs, including fluoroquinolones, warfarin, oral contraceptives, antiepileptic drugs, and cisapride. 

Explaining potential interactions to patients. Adverse interactions can also arise due to patient error. A patient may misunderstand or be unaware of certain therapeutic requirements, which may lead to injury or poor outcomes. 

For instance, one woman who was hospitalized with multiple myeloma was placed on transdermal fentanyl (25 mcg/h). Following hospital discharge, the patient often sat in her favorite heated recliner after applying the fentanyl patch to her back. She soon began to experience nausea and vomiting. Why? Because the application of external heat results in excess fentanyl release.

Although a warning about external heat is included with the packaging of transdermal patches, few patients pay heed to the “fine print.” To minimize preventable medication errors, physicians should carefully review all therapeutic instructions and requirements with their patients.  

Problems with the pump. File this next mix-up under just plain scary: Patients can purchase keys on eBay or Amazon that unlock pain-controlled analgesia pumps, which allow for faster drug delivery! (These days, it seems you can buy anything online.) If a pump has a software code, it's imperative that this feature is activated for additional security. Also, keep an eye on the volume of solution in opioid-infusion bags.

The Institute for Safe Medication Practices (ISMP) encourages healthcare professionals to report medication errors whenever encountered via the ISMP National Medication Errors Reporting Program (ISMP MERP), which is a confidential service.

Safety strategies

Strategies to avoid medication mix-ups can be deployed at every step of the prescription pathway.

With respect to prescription, it’s a good idea to prescribe conservatively to avoid unnecessary medications. In addition, medications should always be reconciled when care is transitioned.

Furthermore, computerized provider order entry systems should be paired with clinical decision support systems to prevent errors at the medication ordering and dispensing stages. Importantly, handwritten prescriptions should be avoided whenever possible.

During dispensing, ensure oversight by a clinical pharmacist. Additionally, tall-man lettering, wherein distinguishing letters in LASA drug names are capitalized, is recommended. One pneumonic that helps with dispensing is the 5 Rs: Right medication, Right dose, Right time, Right route, and Right patient. Of note, automated dispensing cabinets should be used for high-risk medications. 

With administration, it’s important to limit any interruption to permit nurses to safely give medications. Smart infusion pumps should be used for intravenous infusions. Furthermore, multi-compartment medication devices can be useful in cases of polypharmacy. Finally, patient education is clutch, with robust and comprehensible advice doled out.

If you’re interested in learning additional strategies on how to avoid preventable medication errors, resources are available. For example, the ISMP offers a list of look-alike drug names with tall-man lettering.

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