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Preventing Prescribing Errors

Prescribing errors account for the majority of reported medication errors and have prompted health care professionals to focus on the development of steps to make the prescribing process safer. Prescription legibility has been attributed to a portion of these errors and legislation has been enacted in several states to address prescription legibility. However, eliminating handwritten prescriptions and ordering medications through the use of technology [eg, computerized prescriber order entry (CPOE)] has been the primary recommendation. Whether a prescription is electronic, typed, or hand-printed, additional safe practices should be considered for implementation to maximize the safety of the prescribing process. Listed below are suggestions for safer prescribing:
  • Ensure correct patient by using at least 2 patient identifiers on the prescription (eg, full name, birth date, or address). Review prescription with the patient or patient's caregiver.
  • If pediatric patient, document patient's birth date or age and most recent weight. If geriatric patient, document patient's birth date or age.
  • Prevent drug name confusion: For more information, see
    • Use TALLman lettering (eg, buPROPion, busPIRone, predniSONE, prednisoLONE). For more information, see
    • Avoid abbreviated drug names (eg, MSO4, MgSO4, MS, HCT, 6MP, MTX), as they may be misinterpreted and cause error.
    • Avoid investigational names for drugs with FDA approval (eg, FK-506, CBDCA).
    • Avoid chemical names such as 6-mercaptopurine or 6-thioguanine, as sixfold overdoses have been given when these were not recognized as chemical names. The proper names of these drugs are mercaptopurine or thioguanine.
    • Use care when prescribing drugs that look or sound similar (eg, look- alike, sound-alike drugs). Common examples include: CeleBREX vs CeleXA, hydrOXYzine vs hydrALAZINE, ZyPREXA vs ZyrTEC.
  • Avoid dangerous, error-prone abbreviations (eg, regardless of letter-case: U, IU, QD, QOD, µg, cc, @). Do not use apothecary system or symbols. Additionally, text messaging abbreviations (eg, "2Day") should never be used.
  • Always use a leading zero for numbers <1 (0.5 mg is correct and .5 mg is incorrect) and never use a trailing zero for whole numbers (2 mg is correct and 2.0 mg is incorrect).
  • Always use a space between a number and its units as it is easier to read. There should be no periods after the abbreviations mg or mL (10 mg is correct and 10mg is incorrect).
  • For doses that are ≥1,000 dosing units, use properly placed commas to prevent 10-fold errors (100,000 units is correct and 100000 units is incorrect).
  • Do not prescribe drug dosage by the type of container in which the drug is available (eg, do not prescribe "1 amp", "2 vials", etc).
  • Do not write vague or ambiguous orders which have the potential for misinterpretation by other health care providers. Examples of vague orders to avoid: "Resume pre-op medications," "give drug per protocol," or "continue home medications."
  • Review each prescription with patient (or patient's caregiver) including the medication name, indication, and directions for use.
  • Take extra precautions when prescribing high alert drugs (drugs that can cause significant patient harm when prescribed in error). Common examples of these drugs include: Anticoagulants, chemotherapy, insulins, opioids, and sedatives.
To Err Is Human: Building a Safer Health System, Kohn LT, Corrigan JM, Donaldson MS, eds. Washington, D.C.: National Academy Press. 2000.

A Complete Outpatient Prescription1

A complete outpatient prescription can prevent the prescriber, the pharmacist, and/or the patient from making a mistake and can eliminate the need for further clarification. The complete outpatient prescription should contain:
  • Patient's full name
  • Medication indication
  • Allergies
  • Prescriber name and telephone or pager number
  • For pediatric patients: Their birth date or age and current weight
  • For geriatric patients: Their birth date or age
  • Drug name, dosage form and strength
  • For pediatric patients: Intended daily weight-based dose so that calculations can be checked by the pharmacist (ie, mg/kg/day or units/kg/day)
  • Number or amount to be dispensed
  • Complete instructions for the patient or caregiver, including the purpose of the medication, directions for use (including dose), dosing frequency, route of administration, duration of therapy, and number of refills.
  • Dose should be expressed in convenient units of measure.
  • When there are recognized contraindications for a prescribed drug, the prescriber should indicate knowledge of this fact to the pharmacist (ie, when prescribing a potassium salt for a patient receiving an ACE inhibitor, the prescriber should write "K serum leveling being monitored").
Upon dispensing of the final product, the pharmacist should ensure that the patient or caregiver can effectively demonstrate the appropriate administration technique. An appropriate measuring device should be provided or recommended. Household teaspoons and tablespoons should not be used to measure liquid medications due to their variability and inaccuracies in measurement; oral medication syringes are recommended.
1Levine SR, Cohen MR, Blanchard NR, et al. Guidelines for preventing medication errors in pediatrics. J Pediatr Pharmacol Ther. 2001;6:426-442.