Typed and electronic prescriptions can give way to a host of errors. Check out these 5 from one pharmacist who thought he'd seen it all.
As a pharmacist I've seen my fair share of prescription gaffes, and while electronic prescribing has eliminated many mistakes it is certainly not perfect. In part 1 of this series, we looked at 5 head-scratching prescriptions I received while practicing, which ranged from hard-to-read handwriting to interesting diagnoses. In part 2, we're going to look at another sampling of prescription superlatives, but this time we'll be looking exclusively at typed or electronically sent prescriptions. Scroll through the slideshow below to get more details and a few pointers on prescription clarity so you can avoid that pesky pharmacy call in the future.
The most common thing I see in the comments section is additional or conflicting instructions, which leaves the pharmacy unsure of what to put on the label. If we receive directions for “once daily” but also see “twice daily” in the comments, we will call your office to be sure we get it right. What things are perfect for the comments section? Clarifying notes such as orders to discontinue, a child’s weight so the pharmacy can help double-check for appropriate dosing, and notes that a medication is renally dosed (that will save your office a phone call too!).
For more information on common electronic prescribing mistakes, check out pages 14-15 of
from the Institute for Safe Medication Practices (ISMP).
Thankfully we didn’t instruct the patient to inject themselves 14 times per day, especially since these needles would have been used with insulin. We were fairly certain it was supposed to say 1 needle 4 times daily, but we called the prescriber’s office to be sure. A best practice would be to write out at least one of the numbers and the word “needle” to help separate the two such as:
An alternative would be to write “Use four times daily.” Because the only option is to use 1 needle at a time, pharmacists will know what you mean.
This prescription was interesting because most computer systems in a physician’s office would be programmed to prevent 2 different quantities from ending up on the final prescription. A good practice would be to train an office assistant in the essential elements of a prescription and then briefly check the prescription before giving it to the patient or sending it electronically.
Note: Most states (including Florida, where I practice) require the quantity in numbers and letters. Unfortunately, if it is missing, I have to bother your office to get a verbal prescription, or in the case of a Schedule II medication, I wouldn’t be able to fill it.
There are primarily 2 times you want to ensure the dose (in mg) is on the instructions:
When we called the nephrologist’s office they wanted us to dispense 2 bottles to take as a 1-time dose and they were going to recheck the patient’s potassium the next day. What would have made this prescription clearer? Clarifying the quantity because while sometimes we can tell what “1” means if the product selected is obviously a pack (eg, Z-pak, Disp #1), this case was less clear. If the directions were written as a 1-time dose we would have known to dispense 30 g of Kayexalate. Also, adding additional information in the directions section (eg, patient action, quantity, unit of measure) would aid in prescription clarity.
To aid in prescription clarity (and less phone calls from the pharmacy), physicians should remember to include patient action; quantity and/or dose; dosage form or unit of measure; route of administration; frequency; as needed (if applicable); and diagnosis or reason (bonus). For example, if a prescription says, "inject 1 mL under the skin once daily", inject is the patient action; 1 mL is the quantity and dosage form or unit of measure; under the skin is the route; and once daily is the frequency. There might be times when these elements seem obvious, but please include them anyway for patient safety.
To give another example, I once received a prescription for ear drops and the sig was missing the route (to left/right ear) and read “Use 1 drop four times daily.” It’s obvious though right? I went to counsel the patient and he said “it’s supposed to go in my eye!” It turns out the provider selected the wrong product in the EMR. If the directions had included “to left eye” I would have been able to catch the error before it ever got to the patient.