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).

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.

COMMON CAUSES OF ERRORS
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).

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.

RISK FACTORS FOR ERRORS
Physicians in the study identified the following risk factors for prescribing errors:

• Uncomfortable physical work environment.
• Inadequate staffing or new or student staff.
• Heavy workload.
• Prescribing for another physician's patient.
• Lack of communication within the team.
• Impaired physical and mental wellbeing.
• Lack of knowledge.

Organizational factors that were identified included:

• Inadequate training.
• Low perceived importance of prescribing.
• Hierarchical medical team.
• Lack of awareness of errors

References:

REFERENCES:1. Lesar TS, Briceland L, Stein DS. Factors related to errors in medication prescribing. JAMA. 1997;277: 312-317.
2. Bond CA, Raehl CL, Franke T. Medication errors in United States hospitals. Pharmacotherapy. 2001;21: 1023-1036.
3. Ferner RE, Aronson JK. Medication errors, worse than a crime. Lancet. 2000;355:947-948.
4. Finch CK, Self TH. 10 Common prescribing errors: how to avoid them. Consultant. 2001;41:766-771.
5. Dean B, Schachter M, Vincent C, Barber N. Causes of prescribing errors in hospital inpatients: a prospective study. Lancet. 2002;359:1373-1378.
6. Reason J. Human Error. Cambridge, England: University of Cambridge Press; 1990.
7. Department of Health and Social Services. Central Health Services Council Report of the Joint Subcommittee on Measures for Controlling Drugs on Wards (The Gillie Report). HM(70)36. London: DHSS; 1970.