Drug points

A misread abbreviation that led to a digoxin overdose

In this Drug Points article the author describes how misinterpretation of an abbreviation on a drug endorsement led to a digoxin overdose and comments on the issues it raises.
Case summary Mrs D was a 65-year-old female who had been unwell following surgery two weeks earlier. She had developed difficulty swallowing so her oral medication had been converted to liquid. Her digoxin 187.5g each morning was endorsed by the ward pharmacist with = 3.75ml and a 60ml bottle of digoxin elixir 50g per ml was supplied. When writing =, the pharmacists pen trailed ink resulting in the = looking like 2. A junior nurse misread the pharmacists endorsement as 23.75ml. The nurse doublechecked this volume with two senior nurses, asking if they read the endorsement as 23.75ml, and both senior nurses agreed that this was the dose. Mrs D was given 23.75ml digoxin liquid (equivalent to 1187.5g, over six times the prescribed dose). Later that evening, Mrs D became increasingly unwell and bradycardic. She did not present any of the typical signs of digoxin toxicity. The following day, the same pharmacist was asked to supply more digoxin elixir (the original supply should have lasted for two weeks). The pharmacist recognised an error

Facsimile of misread endorsement on drug chart

had occurred and alerted the doctors. Mrs D made a full recovery from the digoxin overdose after she received three vials of digoxin antibody (Digibind each vial binds approximately 500g of digoxin).

rs D received a massive overdose of digoxin as a result of a nurse misinterpreting a pharmacists endorsement of a drug chart. Despite three nurses checking the amount of digoxin to be administered, none performed the simple calculation that would have alerted them to the error. The pharmacists endorsement was misinterpreted because they had used an abbreviation (=) that had become unclear when the pen had trailed ink. Therefore, there are four problems that led to the digoxin overdose: illegible handwriting use of abbreviations failure to double-check calculations inadequate second check.
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Although this administration error occurred in a hospital setting, it has implications for healthcare professionals in both secondar y and primary care.
Handwriting and medication errors

In a hospital setting, pharmacists frequently endorse prescriptions to clarify their meaning or provide administration instructions, as in the case of Mrs D. This is part of the well-recognised safety role that pharmacists play. 1 As with any handwriting, however, these instructions can be misinterpreted. Illegible handwritten prescriptions are well-recognised causes of prescribing, dispensing and admin-

istration errors, and can result in fatalities.2,3 Doctors handwriting is commonly associated with illegibility, although there is no evidence that it is any more illegible than other professionals. 4,5 As such, it is important that all professionals who are handwriting (or endorsing) prescriptions, or writing instructions for patients, pay close attention to the legibility of their writing and the possible misinterpretations. In the UK the majority of handwritten prescriptions are made in a hospital setting, although computerised prescribing will be widely available in the future. In UK primar y care the majority of GP
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Abbreviation using U instead of units omitting a leading 0 for dosages requiring a decimal point writing g instead of mcg or microgram

Potential problem misread as 0 (10-fold increase in dose) dose misread (10-fold increase in dose)

units misread as milligrams (1000-fold increase in dose) misread as 2 mistaken as hydrochlorothiazide misread as number 1 misread as number 2 misread as number 2 misread as number 2 misread as 0 (10-fold reduction in frequency of administration

writing = instead of equivalent to writing HCT instead of hydrocortisone writing / instead of per writing @ instead of at writing + instead of plus or and writing & instead of and writing instead of hour

There is anecdotal evidence that when prescribers write directions in full (eg daily instead of OD or QD), further confusion arises due to illegible handwriting.6 In general, nonstandard and high-risk abbreviations should be avoided. It is important to remember that illegible handwriting will increase the risk of medication errors whether prescriptions are written in full, or with abbreviations.
Avoiding Mrs Ds overdose

Table 1. A selection of abbreviations that can lead to problems

prescriptions are already computer generated and therefore handwriting legibility is less relevant. Handwritten prescriptions, however, are the norm during home visits and for nonmedical prescribers. Therefore, care is still needed to avoid ambiguous directions. Prescribers and endorsers should ensure that they write as legibly as possible with a waterproof pen to avoid ink running (since many prescriptions get wet, especially in hospital) and that does not trail ink. Although writing in capitals can sometimes be easier to read, these can also become illegible if written hurriedly.
Abbreviations and medication errors

A selection of abbreviations thought to be particularly problematic is shown in Table 1. A more complete list is available from The Institute for Safe Medication Practices website, www.ismp.org/ Tools/errorproneabbreviations. pdf. This list has been criticised, for advising against the use of Latin abbreviations.
Drug points

Mrs Ds overdose could have been prevented at a number of points: The prescribing doctor could have stated the digoxin dose in micrograms and millilitres. The pharmacist could have written equivalent to instead of = when endorsing the volume to be administered. The junior nurse could have asked the senior nurses what they thought the prescription said rather than asking if it said 23.75ml. The nurses could have doublechecked the dosage calculation.
References

1. The Audit Commission. A spoonful of sugar medicines management in NHS hospitals. 2001. 2. Bobb A, Gleason K, Husch M, et al.

Abbreviations are also associated with medication errors.3 Although many abbreviations can save time for prescribers and pharmacists, they can also be misread.
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care should be taken with all handwritten instructions to ensure they are legible and avoid unnecessary or confusing abbreviations that can be misinterpreted calculations for volumes to be prescribed, dispensed or administered should always be double-checked; this can be a self-check, or a check by another person when another person double-checks a prescription, the second-checker should read out what they think it says, not confirm what their colleague thinks it says double-checking will only be an effective safety barrier if both individuals take responsibility for the outcome; it is very easy to be complacent when someone else is checking your work, especially when you are busy, tired or distracted

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The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med 2004;164:785-92. 3. Phillips J, Beam S, Brinker A, et al. Retrospective analysis of mortalities associated with medication errors. Am J Health-Sys Pharm 2001;58:1835-41.

4. Meyer T. Improving the quality of the order-writing process for inpatient orders and outpatient prescriptions. Am J Health Sys Pharm 2000;57(suppl 4):S18-22. 5. Schneider KA, Murray CW, Shadduck RD, et al. Legibility of doctors handwriting is as good (or bad) as everyone elses. Qual Saf Health Care

2006;15:445. 6. Cada D. The devil knows latin. Hospital Pharmacy 2003;38:626-8.

Rachel Howard is a lecturer in pharmacy practice at the University of Reading School of Pharmacy

Amitriptyline

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