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Prescribing Errors:Causes-and a Plan to “Do No Harm”

Prescribing Errors:Causes-and a Plan to “Do No Harm”


Because of the potential harm they pose to patients, prescribing errors continue to be a focus of attention in the medical literature.1-4 Indeed, the primary impetus for the creation of this column was to help prevent these errors.

Recently, a prospective study examined the causes of prescribing mistakes. Dean and colleagues5 used theories of human error6 to gain an understanding of the underlying reasons for these errors (Table 1).

  Table 1 — Classification of error-producing conditions
  Work environment  
  Physical environment  
  Staffing (eg, inadequate staffing, new staff members or students, caring for other physicians' patients)  
  Individual factors  
  Physical health (eg, fatigue, hunger, illness)  
  Mental health (eg, low morale)  
  Skills and knowledge (eg, training, experience, calculations)  
  Team factors  
  Task-related factors  
  Absence of protocols  
  Tasks that are not routine  
  Patient-related factors  
  Unhelpful patient  
  Complex disease  
  Language and communication
  Adapted from Dean B et al. Lancet. 2002.5

The study was conducted in a 550-bed teaching hospital in the United Kingdom. Because of the sensitive nature of this subject, prescribers were assured of the confidentiality of the results and of the nondisciplinary hospi- tal policy on errors. All prescribers were aware of the study, and any member of the medical staff was eligible for inclusion.

Pharmacists prospectively identified 88 potentially serious prescribing errors during the period from mid October to mid December 1999.1 The 41 prescribers who made 44 of the mistakes were interviewed, and the findings were analyzed using human error theory.

Most of the prescribing errors resulted from "slips in attention" or the failure to apply relevant rules (Table 2). Certain conditions related to the work environment and to both the team and individual providers also led to prescribing errors (Table 3).

  Table 2 — Examples of active failures that can lead to prescribing errors  
  Type of active failure   Example  
  Slips   Two drugs were acceptable in a given setting: one was prescribed, but
the dose for the alternative drug was mistakenly written. The prescriber
had been distracted by interruptions.
  Lapses   A patient was switched from an immediate-release product to a sustained-release product on the discharge prescription; however, the prescriber forgot to delete the immediate-release product on the chart.  
  Mistakes   The prescriber did not know that the dosage of ciprofloxacin must be decreased in a patient with renal failure.  
  Violations   An attending physician checked the drug names a medical student had written and told the student to fill in the dosages; the attending physician failed to review the dosages later.  
  Adapted from Dean B et al. Lancet. 2002.5
  Table 3 — Examples of conditions that can produce prescribing errors  
  Type of error-producing condition   Examples  
  Related to work environment      
      Workload   The prescriber has an excessive number of patients to cover or is on call 24 hours one day and has 12-hour shifts the rest of the time  
      Caring for other physicians' patients   The physician who takes over the care of a patient finds no reason given in the chart for a drug to be started  
      Hurried prescribing   The physician rushes to get the prescription to the pharmacy because of the delay in sending medications to the floor; prescriptions are written while the physician is on rounds  
  Related to the team   An attending physician checked the drug names a medical student had written and told the student to fill in the dosages; the attending physician failed to review the dosages later.  
      Written communication   Allergies are not documented in charts; messy charts  
      Verbal communication   House officers simply “do as they are told” and thus fail to ask the attending physician or consultant about highly important drug interactions  
  Related to the individual      
      Hunger   The prescriber has not eaten all night and hurries to finish  
      Tiredness   Multiple medications need to be rewritten in a patient's chart in the middle of the night  
      Knowledge   The prescriber is not familiar with the correct dosage of a drug  
  Adapted from Dean B et al. Lancet. 2002.5

Latent conditions that were associated with errors included:

  • Lack of training about dose forms; dosing adjustments for decreased renal function; and the frequency, route, and duration of therapy.
  • Failure to transcribe orders with the same care used when prescribing a new drug.

Examples of defenses included reliance on the pharmacy to verify dosages—sometimes to the extent that the prescriber failed to look up the correct dosage.


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