Consultant. Vol. 42 No. 8

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

By
TIMOTHY H. SELF, PharmD—Series Editor | July 1, 2002

University of Tennessee

Dr Self is professor of clinical pharmacy at the University of Tennessee Health Science Center in Memphis. He has 30 years of experience in a university medical center working with physicians in caring for patients, conducting clinical research, and teaching. He has authored over 200 publications, including more than 120 papers in peer-reviewed medical and clinical pharmacy/pharmacology journals. His clinical research abstracts have been presented at several American Thoracic Society international conferences as well as the American College of Chest Physicians and the American Academy of Asthma, Allergy, and Immunology

Because of the potential harm they pose to patients, prescribing errors continue to be a focus of attention in the medical literature.^1-4Indeed, 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 colleagues⁵used 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. 2002.⁵

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.

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(Drug information on 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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STRATEGIES TO HELP PREVENT PRESCRIBING ERRORS

Current prescribing policies and good practice standards must be adhered to.⁷ These practices include:

Keeping the drug chart with the patient.

Clearly written prescriptions.

Minimal transcription of medication orders.

Having a pharmacist check all medication orders.

Documenting the reason for prescribing a drug in the notes.

Detailing allergies in the chart.

Hospitals need to create a "culture" in which prescribing is viewed as significant. For example, a drug name should always be accompanied by its dose, form, and route of administration; the drug chart should be reviewed on rounds; and any prescribing errors need to be reviewed with the pharmacist. In addition, the hospital should formally review interventions made by pharmacists.
Prescribers need to be aware of situations that are conducive to errors, such as having an extremely heavy workload or caring for another physician's patient.

TOPIC INDEX

Developmental/Genetic

Nutritional/Metabolic

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

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