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Research studies find that American doctors make errors in writing prescriptions at rates of 5 to 81 percent. Most errors in prescribing medications are caught at the pharmacy, but a shocking number of drug prescribe in error find their way to patients.
Choosing the wrong medication entirely or the wrong form of the medication aren't the only ways clinicians can go wrong using e-prescription systems. Here are five more potential problem errors.
3. Missing Overdose Alerts
A middle-aged man with a seizure disorder was admitted to the hospital in status epilepticus, seizures that simply would not stop. The doctors successfully treated his condition with high-doses of anticonvulsant drugs, and after a few days started giving him 1500 mg of a medication called Dilantin (phenytoin sodium). When the man was finally ready to go home, his hospitalist gave him a prescription to continue the 1500 mg of Dilantin daily, instead of a more appropriate dosage of 500 mg a day. Both the doctor and the pharmacist ignored a pop screen that warned "EXCESSIVE DAILY DOSAGE." A few days later, the man was readmitted to the ER, unable to wake up. He was diagnosed as suffering Dilantin toxicity.
Most doctors don't like the alert system in most electronic prescription systems. Pop-up screens warn of allergies, duplicates, potential drug/drug interactions, and inappropriate doses, but the same pop-up screen may appear several times as the prescription is being made. The doctor (or the nurse practitioner) may have to enter the same reason for overriding the warning several times during the process of filling out the prescription. Electronic prescription systems can cause doctors and other prescribers to become desensitized to warnings, and actually increase serious prescription errors.
4. Failure to Adjust Dosage
The sixty-year-old man who is writing this article was admitted to the hospital with sepsis from an infection in a cut on big toe. The Proteus and Klebsiella bacteria that were making him very sick were beginning to spread through his body, and he was put on an IV antibiotic called vancomycin. This potent antibiotic knocks out many kinds of infection, but it also puts severe stress on the kidneys. The effects of the antibiotic on the kidneys are recognized by increasing levels of a protein in the blood called creatinine.
When the patient started the medication, his creatinine levels were zero. Twenty-four hours later they were 0.8, which is still normal. Another twenty-four hours later his creatinine levels were 2.0, which was a sign it was time to look at treatment with other antibiotics to avoid kidney damage. Fortunately for the writer of this article, his doctors adjusted dosage before kidney damage occurred. Some patients on vancomycin have had to go on renal dialysis when they got too much of the drug.
Adjusting medications is especially important for people who have kidney disease, and for the elderly. The most common problem medications are gliptins, metforming, perindopril, fenofibrate, glibenclamide, olmesartan, bisphosphonates, and strontium. It's not a bad idea to ask the doctor about dosage when receiving any of these medications.
5. Interruptions While on the Phone
About one in three US physicians uses a smart phone to send prescriptions to the pharmacy. Interruptions in the process (such as a personal phone call or a personal text) can lead to prescribing errors.
A hematologist was using his iPhone to call in a prescription for a patient who was going to have heart surgery. For the next week, the patient was to receive an unusually high dose of an anticoagulant, 300 mg a day of Plavix (clopidogrel). A text from his housekeeper about a kitchen fire came in while he was sending in the prescription, however, and he forgot to note that the high dosage Plavix was to be discontinued after the surgery. Two weeks later the doctor received word that his patient had had successful surgery, but had died of bleeding in the pericardium that had caused cardiac tamponade, essentially choking off circulation.
6. Errors In, Errors Out
A baby was brought to the doctor's office for treatment of what turned out to be an E. coli infection causing diarrhea. When the child was brought in, the nurse noted her weight as 20 kilos, although her weight was actually 20 pounds. The doctor wrote out a prescription for the antibiotic in a dosage as if the child weighed nearly twice as much as she did. The antibiotic made the diarrhea even worse, and the prescription was only changed when the baby's mother noticed the error on the discharge paperwork.
Even in the United States, body weight is noted in kilograms, not in pounds. Dosages are computed on the basis of the metric system.
Another common error is failure to note pregnancy. Entire classes of drugs are safe except for pregnant women.
7. Ambiguous Abbreviations
Doctors who get in a hurry can leave out leading zeros (the zero in front of the decimal point that indicates that the dosage is less than one unit) or trailing zeros (the zero that indicates the precision to which the dosage is to be measured). For instance, in a handwritten prescription, a dosage of .4 mg might be misread as 4 mg, ten times too much.
- Clinical prescriptions can be especially confusing. In one case, "Dilaudid 0.6 mg Q 10′ PRN (every 10 minutes as needed) was misinterpreted as "Dilaudid 0.6 mg QID PRN (4 times daily as needed)."
- Using the abbreviation "pot" for potassium instead of the chemical symbol "K" (as in a prescription for potassium chloride) can lead to do oddly dispensed prescriptions in states where marijuana is legal.
- The symbol MgSO4 actually stands for a common laxative, magnesium sulfate, although some doctors use it for morphine, morphine sulfate.
- The commonly used prescriptions µg, OU, and D/C need to be written as "mcg," "both eyes," and "discharge" (or "discontinue"), respectively.
Even worse are prescription errors caused by confusing patients, or by failing to discontinue prescriptions that are no longer needed. Protect yourself by letting your doctor know immediately when you experience serious side effects and whenever possible choose doctors whose offices display relaxed efficiency.
- Mohan P, Sharma AK, Panwar SS. Identification and quantification of prescription errors. Med J Armed Forces India. 2014 Apr
- 70(2):149-53. doi: 10.1016/j.mjafi.2014.01.002. Epub 2014 Apr 3. PMID: 24843204.
- Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014
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- Photo courtesy of Charles Williams: https://www.flickr.com/photos/charlesonflickr/3926259585
- Photo courtesy of Open Source Way: www.flickr.com/photos/opensourceway/7496802140
- http://www.cnn.com/2015/09/22/health/doctor-diagnostic-error-iom-study/ http://lifeinthefastlane.com/doctor-exposed-error/