Issue 2 November 2011
Prescribing Matters This newsletter provides feedback and sends reminders to prescribers about issues raised in incidents, Walk Rounds and audits. It supplements MedicationMatters with a focus on safe prescribing.
TARGETING: Illegible orders Writing a medication order is the main form of communicating prescribing, dispensing and administering medicines. Orders need to be interpreted by many different healthcare professionals across both hospital and community settings. Illegible orders cause delays, errors and harm. Any unclear order must be re-written if requested by a staff member. Some local examples Some easy solutions An illegible order led to a transcription error Nifedipine was illegible. The order was re- written as “Mirtazipine”. Both are available as 30mg doses When writing medication orders ensure the next prescriber can transcribe it correctly Hydrochlorothiazide, Glyceryl trinitrate spray, Digoxin 500 microgram stat What are these
To prevent delays and errors in orders for? administration of PRN and STAT orders
Never abbreviate the drug name
Write microgram in full Write clearly Dispense 10 or Although 10mg was intended, the ‘g’ from the 40mg diazepam? sertraline dose made the diazepam dose look like 40mg , which was dispensed.
Always re-read the script to ensure it can be correctly interpreted by others The dose is 210mg 230mg 250mg? 250mg was read and dispensed instead of the intended 210mg. The error was picked up before being administered. ( Chemotherapy agents have a high risk for causing harm when incorrectly given. Any handwritten orders MUST be unambiguous What is the dose of perindopril? The intended dose was 2.5mg, but was transcribed and administered as 12.5mg ( Medication orders are a communication tool. When re-writing charts, also check each order. Ensure your orders can be interpreted - all orders should be this legible! For more information,Look up the Alfred Safe Prescribing Guideline: http://intranet.alfredhealth.org.au/Assets/ContentFiles/1/MedicationManagementSafePrescribing.pdf
How useful is this newsletter? Your feedback is appreciated
Medication Safety Committee, Alfred Health. Medication Safety Pharmacist: (03) 9076 6330
Acute treatment of moderate to severe depression with hypericum extract WS 5570 (St John's wort): randomised controlled double blind non-inferiority trial versus paroxetine A Szegedi, R Kohnen, A Dienel and M Kieser 2005;330;503-; originally published online 11 Feb 2005; BMJ doi:10.1136/bmj.38356.655266.82 Updated information and services can be found at: References This article
Issue 2