How to avoid errors when writing prescriptions

An Institute of Medicine report estimated that between 44,000 and 98,000 persons in hospitals in the United States die annually as a result of medication errors. The incidence of errors in office practice is difficult to tabulate, but the following 1999 case is indicative of the potential for disaster:

A cardiologist wrote a prescription for Isordil 20 mg. Because of the cardiologist's small, cursive handwriting, the pharmacist misread the prescription as Plendil, and dispensed 20 mg pills, which is double the maximum daily dose of Plendil. The patient had a heart attack and died. The patient's family sued both the cardiologist and pharmacist, and a jury found both liable, and ordered them to contribute equally to the award of $450,000 to the family.

Among the most common errors made when prescribing are:

• indication errors (under use of appropriate medication, overuse of a medication and misuse)
• dosing errors
• drug-drug interactions
• inadequate records (non-documentation of adverse drug events or allergies, for example) and
• misread or misinterpreted prescriptions.

This issue focuses on the last-named error. NPs will want to write a prescription in such a way that there is little chance that the individual dispensing the medication will misinterpret or misread the drug, dose, frequency and route of administration.

Many NPs were taught to write prescriptions using the following symbols and abbreviations:

Rx: Digoxin .25 mg
Sig: Take 1 p.o. qd
Disp: 30 1 refill

Some may have assumed that to write a prescription in any other way might be unprofessional. However, trial, error, research and reflection has taught clinicians that abbreviations are often misread or misinterpreted. For example, qd or QD, has been mistaken as qid, especially when a period is placed after the q or the tail of the q is misread as an "i." It is safer to write "daily" or "every day."

Twelve tips regarding use of symbols and abbreviations

1. Write "greater than" and "less than" rather than use > or <, which may be misread as the opposite symbol.
2. Use "per" rather than a slash mark. The slash may be read as the number "1."
3. Use a clear space between drug name, dose and unit of measure. Inderal40mg could be read as Inderal 140 mg.
4. Always use a zero before a decimal when the dose is less than a whole unit. If no zero is written, the decimal may be missed, causing a pharmacist or nurse to dispense 5 mg instead of 0.5 mg.
5. Do not use zeros after a decimal point. The decimal point may not be seen, and the dose may be dispensed as 10 mg rather than 1.0 mg.
6. Write out "nightly" rather than qhs, which can be misread as "every hour."
7. Write out "subcutaneous" rather than SC, which can be misread as "SL."
8. Write out "for 3 days," rather than x3d, which has been mistaken for "3 doses."
9. Spell out "sliding scale," rather than ss, which has been mistaken for 55.
10. Write out "unit" rather than U or u, which has been misread as a zero or 4. One hospital nurse saw 4U as 40, and another saw 4u as 44.
11. Write out "3 times a week," rather than TIW or tiw, which has been mistaken as 3 times a day.
12. Write out mcg or microgram rather than µ, which can be mistaken for "mg" when handwritten.

How to handle medications will names similar to other medications

The Institute for Safe Medication practices estimates that 25% of the 1200-1500 reports they receive every year of medication-related injuries or deaths are due to confusing drug names.

Here is a list of medications with names which look or sound similar to other medications and which have been named in reports of medication errors:

Additional like-sounding or like-appearing drug names:

How to avoid mix-ups

1. Provide both generic and brand names on the prescription or order.
2. Write the purpose of the medication on the prescription or order.
3. Develop a personal policy, office policy or facility policy for giving and taking verbal orders. For example, make it standard policy to repeat the name of the drug, spell the name of the drug, and repeat the dosage ordered.
4. Consider selecting medications without nomenclature problems for your personal, office or facility formulary.
5. Provide patients with written information about their drugs, so that they will notice errors.

Copyright 2006, Carolyn Buppert
This article is taken from The Green Sheet, published monthly from the Law Office of Carolyn Buppert. To order, click here. For more detail on avoiding malpractice, see "Avoiding Malpractice: 20 cases, 10 rules, 5 systems." To order, click here. For more detail on how to avoid prescribing errors, see "Prescribing: Preventing Legal Pitfalls for NPs." To order, click here.

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