EmergencyPedia

Prescribing

The most dangerous thing a doctor can do on a given day is pick up a pen and prescribe…

Prescribing errors remain a significant cause of patient harm. Safe prescribing is not just about writing a prescription, but involves many cognitive and decision-making steps.

Prescribing errors are relatively common and we have discussed this in our previous post. Furthermore, prescribing is becoming more common in medical assessments such as OSCE examinations.

Common errors and pitfalls include the following Top 10:

(1) Write all the patient’s details including Medical Record Number

• Check with the patient that they are correct (right drug, right patient etc.)

(2) Document Allergies – and what that allergy is…

Penicillin allergy is common – clarify the nature of this allergy because patients with Penicillin allergy may do worse in hospital according to a recent American study

(3) Do NOT use brand names.  These can be easily confused by the nurses (and all drugs are stored in drug cupboards as generics so it will take longer for them to find a branded drug).  Prescribing brand names may also lead to drug error especially with illegible handwriting.  I have seen ‘coversyl‘ (ACE inhibitor) mis-dispensed by a pharmacist as ‘coumadin‘ (Warfarin) and the patient presenting to the Emergency Department with bleeding…

• The FDA have also reported that this is a dangerous practice:
  

(4) Use capital letters, sorry, CAPITAL LETTERS.  It is clearly easier to read and therefore safer.  Doctor’s handwriting is notoriously bad.

(5) Follow the “5 Rs”:

(6) Similar looking drugs are easily confused.  This is often an issue in theatre (grabbing the wrong syringe).

(7) Design your system to enhance safety for patients.  This should include clear labelling and the abiluty for doctors to easily check there prescribing on a reliable source such as MIMS, BNF or AMH.

(8) Establish a “culture” for reporting errors (including near misses) and discussion of lessons learned.  Teach your colleagues from your experiences.

(9) For all controlled drugs (e.g. opioids) prescribe fully in words and figures with the amount to be dispensed clearly stated.  Remember to include a contact phone number for where you work for a verbal check.

(10) Get the route of administration (and abbreviation) correct – do not confuse IV and IM routes.  Inadvertent incorrect use of drugs like adrenaline can lead adverse outcomes: 

We have listed some of the important and common routes of administrations with abbreviations below.

In general, it is important when prescribing or administering medications to check doses, write clearly and avoid short hand where possible in order to avoid errors.

The Common Routes of Administration and Abbreviations

Intra-venous (IV)

Intra-muscular (IM)

Subcutaneous (SC)

Intra-osseous (IO)

Intra-peritoneal (IP)

Intra-theccal (IT)

Intra-articular (IA)

Oral (PO)

Buccal (B)

Topical (Top)

Sublingual (S/L)

Intra-nasal (IN)