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

Article

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.

 

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
 
 
Communication
 
 
Supervision
 
 
Responsibility
 

 
Task-related factors
 
 
Absence of protocols
 
 
Tasks that are not routine
 

 
Patient-related factors
 
 
Unhelpful patient
 
 
Complex disease
 
 
Language and communication problems
 

 
Adapted from Dean B et al. Lancet. 2002.

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).

 
 
 
 
 
 
Table 2 - Examples of active failures that can lead to prescribing errors
 
 
 
 
 
 
 
Type of active failure
 
Example
 

 
Errors
 
 
 
 
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.



 
 
 
 
 
 
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.

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.

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