Electronic prescribing (e-Prescribing) has been praised for increasing patient safety by providing clearer prescriptions and reducing medication errors. Pharmacists no longer have to worry about interpreting the prescriber’s handwriting. However, it has been found that even with e-Prescribing, more than 10% of prescriptions still contain an error1. These errors can be highly dangerous, or even deadly. Here we list out our top 5 mistakes found in electronic prescriptions (e-prescriptions) and solutions to prevent them.
1. Wrong Drug Name or Strength
One of the most dangerous medication errors is prescribing the wrong drug or strength. E-Prescribing prevents errors that occur from illegible writing, but incorrect medication errors can still occur. In many e-Prescribing systems, the prescriber selects the drug to prescribe from a lookup. It is easy to see how a rushed prescriber could make a mis-click and pick the wrong drug or strength. Additionally, several drugs have similar names. If prescribers are not careful, they can easily confuse them with each other. Of all medication errors, the FDA reports that about 10% come from drug name confusion2. Several drugs have different strengths and some have different dosage routes as well. For example, Ofloxacin is available in both a 0.3% opthamalic solution and a 0.3% otic solution. Choosing the wrong route could have serious effects. Selecting the wrong drug, strength, or route could even be fatal. This is why it is critical that prescribers double check these fields when selecting a drug to e-prescribe.
A good way to prevent picking the wrong drug name is to use e-Prescribing software that includes tall man lettering to help in selecting look-alike drug names. These drug names include both lower and upper case letters in order to draw attention to the differences in their names. For example, two similarly named insulins are listed as NovoLOG and NovoLIN to differentiate between them.
2. Unclear Directions
The most important part of a prescription for the patient is the directions. If the patient does not understand how to take/use the prescription, they will not get the intended results and it could be potentially harmful. A common mistake in e-prescriptions is to write directions that include abbreviations, are incomplete, or that say something generic like “Take as directed.”
The directions must be written out fully in terms that the patient will understand. They should not include any abbreviations or anything that the pharmacist would need to interpret or rewrite. While pharmacists may understand the abbreviations, the reality is the busy pharmacist (or rather pharmacist assistant) will quickly re-write it or a computer program will re-write it for them and the translation is many times incorrect. These mistakes can be fatal. For example, the FDA reported a patient died when 20 units of insulin was abbreviated as "20 U," and the "U" was mistaken for a "zero"3. The patient received an incorrect dose of 200 units as a result.
Prescribers must also not assume the patient will remember the directions they gave them orally – Including the full directions in the electronic message to the pharmacist gives the patient written clear directions they can check if they cannot remember what the prescriber told them. Directions should always include when, how often, and how to take the medication
It is also important to make sure any numbers written in the directions are safely written. Decimal points can be easily missed. For example, 1.0 could be quickly read as 10 or .1 could be read as 1. Prescribers should never include a decimal point and a trailing zero (X.0mg) but should always include a leading zero before a decimal point (0.Xmg). It is recommended to try to avoid the use of zeroes by using alternative units of measure – for example use “50 micrograms” instead of “0.05 milligrams.”
3. Including Directions in the Wrong Place
Another common mistake in e-prescriptions is including direction information in a note or comment field. The note field is a helpful field that allows prescribers to add additional free text information that is not part of the prescription. However, this field should never be used for drug name, directions, the number of days, or any important information. Many prescribers feel the need to include direction information in the note field because their e-Prescribing software does not allow them to enter custom directions. It is quite challenging to prescribe medications that require tapering or titrations if the prescriber can only enter pre-structured directions. The problem is most of the pharmacy software does not show the note information on the main dispensing screen and this makes it easy for the pharmacist to miss it. This can then cause the pharmacist to include incorrect or incomplete directions. Prescribers sometimes include conflicting direction information in the pharmacy note box as well. For example a conflict might look like:
Directions: 3 times a day
Free Text Note: 1 GTT Q4 OD – patient has a coupon
If the pharmacist fills based on directions, they have no idea how much the patient should take three times a day. If the pharmacist happens to check the free text note field, they now know how much but have conflicting “how often”. This causes the pharmacist to have to contact the prescriber for clarification and slows down the entire process of e-Prescribing. This is why it is critical for prescribers to include the full directions in the directions box and only use the pharmacy note field for additional information. A proper prescription might look like:
Directions: 1 drop in the right ear every 4 hours daily
Free Text Note: Patient has a coupon
Using e-Prescribing software that allows prescribers to easily free text any custom directions needed, as well as customize their sig and direction lookups, is a great solution for preventing information being placed in the wrong field. Using these solutions, as opposed to solutions where prescribers can only select pre-structured directions or have to complete complicated extra steps to have detailed directions, is an ideal way to avoid this information from being unseen or conflicting.
4. Incorrect Dosage
Another highly dangerous medication error is prescribing the wrong dosage. It is easy for a prescriber to make a mistake when converting units of measurement or calculating a dose. These mistakes can result in doses 10 or 100 times the intended amount. For example, an infant recently died after receiving an overdose of morphine when a 3.5mg dose was given rather than what should have been a 0.35mg dose. There have been many other cases where these kinds of mistakes have led to fatalities as well. This is why it is important for prescribers to check and double check the dose they are prescribing.
A great solution for prescribers is to use an e-Prescribing system that includes dosing references and a dosing calculator at the point of prescribing. These calculators help prevent calculation errors and give warnings if the calculated doses are too high. These are especially useful for pediatrics per weight based dosing. In some systems, like MDToolbox, it will even convert mg per kg to mL automatically if needed for prescribers.
5. Wrong Quantity
Prescribers also make the mistake of including a quantity for either the number of days the prescription is for or the amount to be dispensed that is wrong in e-prescriptions. Prescribing more or less of a medication than intended can have serious effects. This is why it is important for prescribers to double check the dispense amount and the number of days it should last. It is important that these amounts do not contradict each other or the directions, otherwise the pharmacist will not know which is the correct amount.
An example of a contradicting prescription:
Directions: Take 1 Tablet Daily for 5 days by Mouth
Days Supply: 5
Dispense #: 20
How many should the pharmacist dispense? Does the patient need to take 20 pills over the next five days? Or, do they only need to take one daily for five days and thus, only five tablets should be dispensed? A patient could have serious adverse effects if they take the wrong amount of a prescription. To ensure safe prescribing, a quality prescription should look like:
Directions: Take 1 Tablet Daily by Mouth
Days Supply: 5
Dispense #: 5
To further prevent quantity errors, prescribers can use software (like MDToolbox) that helps them with auto calculating these amounts based on the directions and either the selected number of days or dispense number.
In addition to avoiding these mistakes, there are further steps prescribers should take to prevent medication errors. They should always take the time to double check the complete prescription information before hitting e-Send. Taking this small extra step can help catch a lot of unnecessary errors. Prescribers should also make sure that the patient is clear about which prescription they are prescribing for them and the proper way to take/use it. This way the patient can double check they are receiving the right prescription from the pharmacy and be able to use it as intended. Prescribers should also use e-Prescribing software that allows them to print patient leaflets, as well as a medication summary that lists the prescriptions to give to the patient. Medication summaries are a good way to remind the patient which medications were prescribed, how often to take them and which pharmacy they were e-Sent to.
E-Prescribing continues to improve prescription safety. We can take patient safety to the next level and minimize medication errors even further with a combination of prescribers following a few simple guidelines, double checking their prescriptions and using patient safety focused e-Prescribing software.
If you have comments or suggestions for our blog or would like to learn more about MDToolbox’s e-Prescribing solutions we would love to hear from you! Please leave a comment below, use our contact form or email us any time at firstname.lastname@example.org.
- Nanji KC, et al "Errors associated with outpatient computerized prescribing systems" J Am Med Inform Assoc 2011; DOI:10.1136/amiajnl-2011-000205.
- Rados C. “Drug name confusion: preventing medication errors.” FDA Consumer Magazine. 2005;39. www.fda.gov/fdac.
- "Strategies to Reduce Medication Errors: Working to Improve Medication Safety." U.S. Food and Drug Administration, 12 Apr. 2013. Web. 09 Jan. 2014.