A Pharmacist’s 4 Top Tips for Safe Prescribing

August 23, 2018

Alex Evans works in community pharmacy in Kihei, Hawaii. He is also a PADI assistant scuba instructor.

Highlights include: Eliminating dangerous drug abbreviation habits, easy-to-use online drug interaction checkers, and more.

I have been a community pharmacist for about 8 years, and in that time have seen my fair share of prescriptions and/or practices that could have led to harm. I know that I am not alone and so I wanted to take the chance to highlight 4 error-prone areas that come to mind first when I take a look back.

One of the best resources to learn more about improving prescribing practices is the Institute for Safe Medication Practices (ISMP), referenced throughout this article.

ISMP has a list of dangerous abbreviations you can download and print for your office
Prioritize eliminating abbreviations associated with the highest risk medications in your practice (eg, insulin, anticoagulants, opioids, drugs in pregnancy)
Make a goal of stopping use of one abbreviation at a time, over a set period, until they have been eliminated

Focusing on one abbreviation at a time will help ensure that the new habit sticks. I did that with “QD” in pharmacy school (I actually write out quite a few prescriptions too when I take them as verbal orders) and got in the habit of writing “Qday;” it quickly became second nature.

There are numerous drug interaction checkers, including apps – they are all your friends!
When the pharmacist calls you about a drug interaction, the best practice is to personally take the call
Be sure to include medications that other providers have written when checking interactions

Three popular online databases to check interactions that I recommend are: Facts and Comparisons® eAnswers, Lexi-Comp, and MicroMedex. All provide information on drug uses, dosing, administration, warnings and precautions, interactions, pharmacodynamics and pharmacokinetics, and other essential features and characteristics. The services provide a suite of tools including a drug interaction checker. Enter a list of a patient’s medications and it will screen and cross screen for potential interactions.

Never write the dose out in tablespoon or teaspoon-always write both the volume (in mL) and dose (in mg or other appropriate unit) on the prescription
Write the child’s weight on the face of the prescription so we can double-check the dose
For antibiotics especially, it helps us if you write the indication

has identified use of metric units only for dose and weight and ensuring documentation of metric weight on electronic and printed prescriptions as a targeted best practice for 2018-2019. Michael Gaunt, a pharmacist with ISMP, wrote a brief article on oral solution prescribing safety that I highly recommend. Also, if you provide the indication we can ensure we look up and check the correct dosing. For example, for amoxicillin we would need to know if you are writing the high-dose 80 to 90 mg/kg for otitis media5 or if you intended to prescribe a lower dose for something else.

E-prescribing eliminates many sources of errors, but also introduces opportunities for new errors
Drug product mix-ups are particularly common
Be careful with units when assigning a quantity

Another thing that often causes confusion in the pharmacy is the drug formulation. For example, bupropion, which comes in 12- and 24-hour formulations, or mix-ups between MacroBID and MacroDantin, are easier to make with e-prescribing because all products will populate on the list. For further explanation of some of the most confusing drug formulations, my recent article for Pharmacy Times may be of interest.

References:

1. Institute for Safe Medication Practices. List of error-prone abbreviations. https://www.ismp.org/recommendations/error-prone-abbreviations-list. Published October 2, 2017. Accessed August 23, 2018.
2. Institute for Safe Medication Practices. High-alert medications in community/ambulatory settings. https://www.ismp.org/recommendations/high-alert-medications-community-ambulatory-list. Published November 20, 2017. Accessed August 23, 2018.
3. Institute for Safe Medication Practices. 2018-2019 targeted medication safety best practices for hospitals.

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4. Gaunt M. Prescribing and dispensing errors with oral solutions. Pharmacy Times. https://www.pharmacytimes.com/publications/issue/2017/march2017/prescribing-and-dispensing-errors-with-oral-solutions. Published March 20, 2017. Accessed August 23, 2018.
5. Evans A. Top 5 drugs with confusing formulations. Pharmacy Times. https://www.pharmacytimes.com/contributor/alex-evans-pharmd-cgp/2017/01/top-5-drugs-with-confusing-formulations. January 5, 2017. Accessed August 23, 2018.