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Search results for "Ordering/Prescribing Errors"

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Journal Article > Study

Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study.

Alassaad A, Gillespie U, Bertilsson M, Melhus H, Hammarlund-Udenaes M. J Eval Clin Pract. 2013;19:185-191.

Medication reconciliation revealed a high rate of prescribing and transcribing errors in the discharge medications of elderly patients at a Swedish hospital.

Journal Article > Study

Ambulatory prescribing errors among community-based providers in two states.

Abramson EL, Bates DW, Jenter C, et al. J Am Med Inform Assoc. 2012;19:644-648.

This study, one of the first to analyze prescribing errors in community primary care practices, found a remarkably high rate of errors. Nearly one in four prescriptions contained at least one error in dosing, frequency, or patient instructions, and a startling proportion of prescriptions had illegibility errors as well. Computerized provider order entry (CPOE) could have prevented a large proportion of these errors, and recent studies have shown that CPOE can decrease prescribing errors in community-based office practices. A Patient Safety Primer discusses outpatient medication prescribing errors and other pressing safety issues in outpatient practice.

Journal Article > Study

High incidence of medication documentation errors in a Swiss university hospital due to the handwritten prescription process.

Hartel MJ, Staub LP, Röder C, Eggli S. BMC Health Serv Res. 2011;11:199.

Illegible handwriting has been cited as a major factor in several high-profile medication prescribing errors. This Swiss study found that the majority of handwritten prescriptions were considered "bad or unreadable," and more than half of the medication errors in this study were ascribed to transcribing errors attributable to poor handwriting.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:463-464.

This monthly selection of error reports shares examples of topical anesthetic error, methotrexate overdose, and child-proof medicine cap dangers.

Journal Article > Study

Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients.

van Doormaal JE, van den Bemt PM, Mol PG, et al. Qual Saf Health Care. 2009;18:22-27.

This study found that only a minority of prescribing and transcribing errors lead to preventable adverse drug events. The authors suggest that future preventive strategies focus on the subset of therapeutic errors, which are the most clinically relevant and are potentially addressed with greater clinical decision support.

Journal Article > Study

Medication errors in a neonatal intensive care unit. Influence of observation on the error rate.

Campino A, Lopez-Herrera MC, Lopez-de-Heredia I, Valls-i-Soler A. Acta Paediatr. 2008;97:1591-1594.

Review of prescriptions by a pharmacist was associated with a reduction in prescribing errors in a neonatal intensive care unit.

Journal Article > Study

The impact of abbreviations on patient safety.

Brunetti L, Santell JP, Hicks RW. Jt Comm J Qual Patient Saf. 2007;33:576-583.

Avoiding use of unclear or misleading abbreviations is a key step in preventing medication prescribing errors, and the Joint Commission mandates avoiding specific abbreviations as one of its National Patient Safety Goals. This study analyzed Medmarx data from 2004 to 2006 to determine the prevalence and impact of errors related to abbreviations. Despite dissemination of the Joint Commission's ''do not use'' abbreviation list, errors involving these abbreviations occurred more than 18,000 times during the study period, although few patients were harmed as a result.

Press Release/Announcement

Governor signs Executive Order creating new Division of Patient Safety.

Evanston, IL: Office of the Governor; July 13, 2006.

This news release announces the governor's plans to improve patient safety in Illinois, including the use of e-prescribing by all providers and a Division of Patient Safety within the state public health department.

Journal Article > Study

A practical approach to measure the quality of handwritten medication orders: a tool for improvement.

Garbutt J, Milligan PE, McNaughton C, Waterman BM, Dunagan CW, Fraser VJ. J Patient Saf. 2005;1:195-200.

Investigators assessed handwritten medication orders and categorized the most common prescribing errors.

Journal Article > Commentary

Medication orders are written clearly and transcribed accurately – implementing Medication Management Standard 3.20 and National Patient Safety Goal 2b.

Laselle TJ,May SK. Hosp Pharm. 2006;41:82-87.

The authors describe efforts to promote clear medication orders at a tertiary care level-one trauma center.

Newspaper/Magazine Article

Death by handwriting.

Glabman M. Trustee. October 2005;58:29-32.

This article discusses several strategies implemented by hospitals to improve the legibility of physicians' medication orders.

Newspaper/Magazine Article

Rx for a better prescription. Hospital bans doctors from using confusing medical abbreviations.

Hall J. The Free Lance-Star. September 25, 2005.

This article presents one hospital's program to reduce the use of dangerous abbreviations. The hospital reports a significant reduction in inappropriate abbreviation use since launching their initiative.

Tools/Toolkit > Fact Sheet/FAQs

Eliminating Dangerous Abbreviations, Acronyms and Symbols.

Medication Safety Issue Briefs, Series III. Health Forum. June 2005;79.

Providing examples from three health care organizations, this briefing presents ways for hospitals to eliminate the use of dangerous abbreviations.

Cases & Commentaries

Dangerous Dapsone

  • Web M&M

Tom Bookwalter, PharmD; June 2004

A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone.

Cases & Commentaries

XL or Smaller?

  • Web M&M

Eran Kozer, MD; June 2003

A boy given an overdose of nifedipine rather than its extended-release (XL) form suffers dangerous hypotension.

Cases & Commentaries

Medication Overdose

  • Web M&M

Rainu Kaushal, MD, MPH; April 2003

A boy received an overdose of phenytoin due to ambiguous use of abbreviations.

Journal Article > Study

Diet order entry by registered dietitians results in a reduction in error rates and time delays compared with other health professionals.

Imfeld K, Keith M, Stoyanoff L, Fletcher H, Miles S, McLaughlin J. J Acad Nutr Diet. 2012;112:1656-1661.

In this study, a hospital policy that allowed registered dieticians to directly enter physician cosigned diet orders for patients significantly decreased nutrition-related error rates and time delays.

Journal Article > Study

ASHP national survey of pharmacy practice in hospital settings: prescribing and transcribing—2007.

Pedersen CA, Schneider PJ, Scheckelhoff DJ. Am J Health Syst Pharm. 2008;65:827-843.

The American Society of Health-System Pharmacists (ASHP) offers policy positions, statements, and guidelines to ensure safe inpatient medication administration. This study highlights their findings from a survey of more than 1200 pharmacy directors across the country. Major trends identified since past administrations of the same survey include a gradual decline in use of the formulary system, an increase in the use of clinical practice guidelines, a growth in methods to improve prescribing practices, and rapid changes in practice driven by accreditation standards. The authors conclude that pharmacists are responding to changes in the health care system and driving efforts to improve medication use.

Journal Article > Study

Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic.

Jani YH, Ghaleb MA, Marks SD, Cope J, Barber N, Wong IC. J Pediatr. 2008;152:214-218. 

Complex drug regimens have been associated with medication errors in pediatric ambulatory practice. This study found that a commercial electronic prescribing system nearly eliminated handwriting errors in a pediatric specialty clinic, though actual adverse drug events were not measured.

Journal Article > Commentary

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:181–182.

This monthly selection of medication error reports provides examples of problems related to abbreviations, electronic prescribing, and communication of critical lab values.

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