BETTER ACCURACY IN WRITING AND DISPENSING OF PRESCRIPTIONS
Anita Walsh
Western Governors University

Prescriber writing errors happen in all forms, places and types. From what the medical staff thinks, the prescriber has prescribed and calls in to the local retail pharmacy, hospital pharmacy, or even the in house pharmacies: adding that the pharmacy processing these uncorrected prescriptions that end up getting to patients. If someone does not catch these errors whether it is the pharmacist, being asked by the patient, why there receiving this drug, because they thought doctor said something else. Therefore, the pharmacist may check it. In a hospital, setting a nurse may look at a chart and question the drug, and call and verify. However, many times no one questions it until the patient has a reaction, or what he or she are being treated for gets worse. Along with communicating with the prescribers, their offices, hospitals, patients, pharmacists also have to be up to date on the all laws, federal and state, and be watchful for those that try to fill fraudulent or altered scripts. Research suggests that there would be significant benefits if all prescribers would follow the same procedures for writing prescriptions, such as using computer generate prescriptions or E-scribe, because there would be a decrease in prescription writing errors, pharmacy mistakes and prescription fraud. Pharmacies call prescribers offices to clarify prescriptions information, on average 150 million times yearly. That’s what makes E-prescribing a valuable tool, it would monitor for drug interactions, by letting the prescriber know if there is a conflict with other medications (meds) the patient may be on, and gets rid of illegible prescriptions. (Anderson, 2006) Anderson (2006) states there are 530,000 drug reactions that injured outpatients, under Medicare that could have been prevented. Over 380,000 to 450,000 drug reactions happen in our hospitals and a horrifying 800,000 drug interactions in our nursing homes. Anderson (2006) states these errors are due to our broken healthcare programs, along with our pharmaceutical companies producing drugs that are more complicated than ever before. Patients may not be getting what they really need because prescribers do not quite understand what they are or do when mixed with other medications. Anderson (2006) supports the updating of computer systems to catch these errors and to print out the scripts to keep patients from being at risk. Cohen (2006) agrees Anderson when it comes to the risk of drug errors; he talks of the mislabeling and the mistakes of look-alike labels on medication. A nurse receives meds from the hospital pharmacy; they receive what should be two vials of a diuretic furosemide 20mg (10g per/ml in 2ml vial) for injection. As the nurse verifies meds for patient, she sees the Pharmacist has made an error, one vial was correct, the other was a sedative made by the same manufacturer in a look-alike container and label. If the nurse had not verified the label and drug, her patient could have suffered a drug interaction. (Cohen 2006) In another incident, an illegible prescription was faxed to a long-term care (LTC) facility and misread by the Pharmacist. What it was supposed to be was an alpha-adrenergic (Cardura 2mg) the pharmacy gave the LTC facility a blood thinner (Coumadin 2mg) for the patient. The error was not caught until 20 days later when the patient was rushed to the hospital for uncontrolled blood pressure. Luckily, he did not have any bleeding problems due to the blood thinner. According to Cohen (2006) these drugs are mistaken often in written orders due to the fact they are both available in the same mg and are take one tablet once a day. Prescribers should at least put what the patient’s diagnosis on the order so these errors do not happen with these sounds alike, look alike drugs, and take the time to write more legible. As more drugs come out with similar packaging and sound alike names these errors are happening more frequently. (Cohen 2006) There largest number of adverse reactions happened because of inappropriate use of dosage forms Lesar (2002) did a study to appraise the individual recurrence and potential adverse reactions or prescribing errors using incorrect dosage. In Lesar’s (2002) study there were 1,115 significant prescriber errors using the wrong dosage form. Over a 60-month timeframe, yearly error numbers increased during the study. The most common error found over the last 16 months related to 402 errors that demonstrated failure to indicate the use of control release formulas 69.7% of the time, whether they used brand or generic . During the study, the most common mistakes were with cardiovascular medications over 208 cases that are almost 52 % of the errors, 2 ending in death. People working as Pharmacists, Technicians, Nurses, and Prescribers have to start being more careful and begin to double check their own work as well as others to prevent these errors. Errors are too many times being swept under the rug, under reported, and no one seems ready to find solutions to these problems and seek help in making sure they don’t happen. A better use of computer programs would help with these problems. People actually checking their own work and question something that does not seem right. Taking the first step into inquiring about these, errors might save a life or at least stop someone from being hospitalized for no reason. (Lesar, 2002) Prescribers should be more aware of what they are writing for, the accuracy of what they have written and it should be legible to the patient, office staff and pharmacy staff. They should also take responsibility for how their staffs are trained in office procedures, whether by them or an office manager. In the Kennedy, Littenberg, Callas, Carney, 2011 study, they introduced modified paper script pads, given to 327 prescribers that were suitable for the study. Only 111 prescribers entered the program and 87 finished the program. These prescribers were from the highest populated rural areas in Northeast Vermont, Southern part of West Virginia, Midwestern part of South Dakota and Western Montana. In the study, they were given 100 scripts with a modified format that would assist the prescriber in filling all these legal requirements of script writing. They had explicitly pre-typed prompts to assist in stopping dangerous abbreviation errors. The second type were like the pads they were used to writing on, both had duplicates that had specific numbers so they could be identified in the study . (Kennedy, et al. 2011) The prescribers sent the duplicates to the study group to be evaluated. Over 16,061 scripts were in the study, 987 scripts there was at least one error. In the end, the modified scripts that follow the laws had more errors then the regular pads; prescriber is not checking what they have written. But then again before the study, guesstimates of one out of every 131-outpatient deaths are caused by medication errors. Paper scripts are the main means of communication from prescriber to the pharmacists, if they contain one or more errors, then that’s millions of scripts that could cause probable harm to patients if these errors go undetected. (Kennedy, et al. 2011) Computer assisted prescribing in Emergency Departments is one attempt at downsizing the amount of medication errors that plague our health system, especially in Emergency Departments. (Bizovi, et al. 2002) Adverse drug events are a large part of medical errors, and are a major cause of injury due to wrong diagnosis or treatment of the patients. According to Bizovi et al. 2002, they say that over 40,000 Americans die each year because of these adverse drug events. The use of computers programs are rapidly becoming an alternative fix to these incidents. The Oregon Health & Science University Emergency Department installed a Computer Assisted (CA) prescription writing system, which gave them the chance to evaluate the difference between handwritten scripts errors and the computer assisted ones. During the time for handwritten scripts, 7036 patients, 2326 scripts for 1459 patients. There were 91 calls from the pharmacy to verify information, and 54 handwritten errors. Once they installed the computer-assisted prescription writing system, there were 7845 patients, 1594 CA scripts, for 1056 patients, there were only 13 verifications, and 11 errors. The CA scripts definitely cleared up errors by 5 times less verifications by pharmacists and 3 times less medication errors. Computer assisted prescription writing has demonstrated that it can catch directional errors and drug conflicts, before they ever leave the prescribers hand. (Bizovi, et al. 2002) Gandhi, Weingart, Seger, Borus, Burdick, Poon, & Bates 2005, focused on using basic computerized systems, they found that out of the 1202 patients, they screened 1879 scripts. Out of that 143 of them contained prescriber errors, 3 led to preventable adverse drug effects; 62 of them had the possibility of injuring the patients, 12 seriously and one was life threatening. According to Gandhi, et al.2005, they feel this is not much of an improvement over handwritten scripts. The physician analysis felt that the advanced prescription writing system would have been better, because it has drug dose and frequency checking and it could have avoided 138 of the 143 prescriber errors and 59 of the 62 adverse drug events. All by a system that requires complete scripts and provides mandatory default dosing and the manufacture recommended times a specific medicine should be taken. (Gandhi, et al.2005) In this era of “Hope & Change” with the rising unemployment, housing market crashes add to that rising numbers without Health insurance. Ginzburg, Barr, Harris & Munshi 2009, state the amount of healthcare costs these days are astronomical; they have calculated that $37.6 billion dollars have been spent in drug errors, yearly and an estimated 7000 deaths annually. The Food and Drug Administration, has calculated, almost 20 % of errors are due to improper dosing. Ginzburg, et al 2009, wanted to see how effective weight-based prescribing with an electronic health record was on prescriber errors. They made a list of patients, infant to 12 years of age that were seen at the clinic and received scripts from prescribers for infant or children’s ibuprofen or acetaminophen, and have a recent weight on file. (Ginzburg, et al 2009) Ibuprofen should be dosed as 5 to 10 mg/kg every 6 to 8 hours as needed and acetaminophen 10 to 15 mg/kg every 4 to 6 hours, as needed. The errors are in categories of strength overdoses, under doses, schedule overdose and under dose and unintelligible directions. In their findings, they discovered that when using the electronic health chart, they had significantly less errors, then in the pre-group, 103 versus 46 errors, also fewer strength errors. So therefore this gives strength to the notion, that weight-based dosing calculator in an electronic health chart prescribing system significantly reduces errors. (Ginzburg, et al 2009) In the Marwaha, Marwaha, Wadha & Padi 2010, they studied two medical centers, one with 3 prescribers, the other with four, without their knowledge and that were within 5 miles of each other. Their main goal was to see if they could find ways to reduce errors in regular practices and minimize the risk to patients. The prescriptions were collected from two pharmacies for 2 months. They found errors in two ways; by a script return book, which they recorded why scripts where sent back, and any mistakes caught and reported by patients, e.g. incorrect quantities or doses. (Marwaha, et al. 2010) They found that 25 percent of the errors were scripts had no directions at all. In addition, that almost 18 percent were regular scripts documented incorrectly and 11 percent directions were incomplete, not legible or written “as directed”. (Marwaha et al. 2010) In their conclusion, they discuss how these script errors are described as error in writing prescription or error in prescribing judgment. Marwaha et al., 2010 feel that medical students not having enough ward-based experience, more time is spent in lectures and tutorials cause these mistakes. So in a practical aspect they are lacking in junior doctors work, learning to prescribe safely. They also are studying less in pharmacology. Their lack of knowledge can be a big problem when it comes to prescribing medications to patients and not endangering them. Electronic prescribing may alleviate some of these problems of writing errors. With other programs can even address medication interactions, and improper dosing. (Marwaha et al. 2010) By using these Computerized Prescribing Order Entry systems, (CPOE) it would improve their prescriber errors and not endanger patients as much. These errors would be easily traced, to who caused them, whether it is the prescriber, staff or pharmacists. In studying Moniz, Segar, Keohane, Bates, & Rothschild 2011, they also favor the use of computerized prescriber order entry. They conducted a before and after trial of clinics that had converted to these systems and e prescribing, and analyzed the differences. These errors were reduced by half, by sending them via e-scribe directly to the pharmacies instead of giving them to the patients. (Moniz et al. 2011) The dispensing of Controlled Substances is one of the most critical parts of everyday pharmacy for a pharmacist, their staff and patients. They have to follow a strict codes and regulations when it comes to the dispensing of this Class II thru V medications. The strictest is on Class II medications, these have to have a written copy or hard copy prescription presented at the pharmacy each time a patient needs these kinds of medications and there are no refills. Only in extreme emergencies do they allow Class II prescription to be called in by the prescriber, but it must be followed up with a written script mailed to the pharmacy in 7 days. (Spies, 2008) Regulations for III thru V are not quite as strict, the prescriber’s office staff, faxed in, may phone them in and have five refills in 6 months. Spies, (2008) also talks of the DEA’s proposal to allow electronic sending of these types of scripts. It would give hospitals, prescribers and pharmacies a lot less paperwork to turn in to the DEA, which would also reduce the amount of forged controlled substance prescriptions. (Spies, 2008) In the end, it is critical that pharmacists and staff maintain an up to date knowledge of all laws federal and state, of laws to maintain a healthy environment for their patients. Research suggests that there would be significant benefits if all prescribers would follow the same procedures for writing prescriptions, such as using computer generate prescriptions or E-scribe. There would be a decrease in prescription writing errors, pharmacy mistakes and prescription fraud. If prescribers would use Computer Assisted weight based prescription writing with electronic records, they would be able to catch their own errors before they left the office. If they used these technologies, it would cut the number of calls from pharmacies verifying prescriptions. It would also have a big effect on prescription fraud by sending the scripts by E-scribe or by Fax to the pharmacies. Drug seeking patients would not have a chance to alter the quantities, directions or strengths on these prescriptions. In essence if we can see these changes are beneficial to the health of the patients. Prescribers, pharmacies, and staff need to really start taking a hard look at the time, money and effort that could be saved. If prescribers went to an electronic prescribing program at all prescribers offices. In the long term, it would cut down on prescription writing errors, pharmacy mistakes, and the access for drug seeking individuals would be vastly limited, thereby preventing prescription fraud.

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