Recommendations to Enhance Accuracy of Prescription/Medication Order

Writing

Personnel to whom this applies: prescribers; nursing or pharmacy staff

(who transcribe verbal prescription orders or rewrite transfer or
admission orders when entering or leaving a health care facility); health
care administrators/managers.

Technology plays an important role in the delivery of healthcare. Use

technology, as appropriate, but evaluate its effectiveness on an ongoing
basis. While technology can reduce medication errors and enhance patient
safety, it also has the potential to cause new types of unintentional errors.
Whenever technology is selected and implemented, it should meet the
requirements of this statement.

The Council recommends the following:

1. All prescription documents are legible. Verbal orders should be

minimized. (See the Council's Recommendations to Reduce
Medication Errors Associated with Verbal Medication Orders and
Prescriptions)

2. Prescription orders should include a brief notation of purpose (e.g.,

for cough), unless considered inappropriate by the prescriber.
Notation of purpose can help further assure that the proper
medication is dispensed and creates an extra safety check in the
process of prescribing and dispensing a medication. The Council
does recognize, however, that certain medications and disease
states may warrant maintaining confidentiality.

3. All prescription orders are written in the metric system except for
therapies that use standard units such as insulin, vitamins, etc.
Units should be spelled out rather than writing "U." The change to
the use of the metric system from the archaic apothecary and
avoirdupois systems will help avoid misinterpretations of these
abbreviations and symbols, and miscalculations when converting to
metric, which is used in product labeling and package inserts.

4. Doses for oral liquids be expressed using only metric weight or

volume, e.g mg or mL. If mLs are used it should be associated with
a concentration or total dose in milligrams.
5. Prescribers should include patient-reported age and, when
appropriate, weight (metric units is the preferred scale) of the
patient on the prescription or medication order. The most common
errors in dosage result in pediatric and geriatric populations. For
weight-based or body surface area-based drugs, the dose basis
should be included. The age (and weight) of a patient can help
dispensing health care professionals in their double check of the
appropriate drug and dose.

6. Prescriptions/medication orders include drug name 1, exact metric

weight or concentration, and dosage form. Strength should be
expressed in metric amounts and concentration should be specified.
Each order for a medication should be complete. The pharmacist
should check with the prescriber if any information is missing or
questionable.

7. A leading zero always precedes a decimal expression of less than

one (use 0.4 mg instead of .4 mg). A terminal or trailing zero
should never be used after a decimal (express as 4 mg, not 4.0 mg).
Ten-fold errors in drug strength and dosage have occurred with
decimals due to the use of a trailing zero or the absence of a
leading zero.

8. Prescribers avoid the use of abbreviations including those for drug

names (e.g., MOM, HCTZ) and Latin directions for use. The
abbreviations in the chart below are found to be particularly
dangerous because they have been consistently misunderstood and
therefore, should never be used. The Council reviewed the uses for
many abbreviations and determined that any attempt at
standardization of abbreviations would not adequately address the
problems of illegibility and misuse.

9.

10. Prescribers avoid vague instructions such as "Take as directed" or

"Take/Use as needed" as the sole direction for use. Specific
directions to the patient are useful to help reinforce proper
medication use, particularly if therapy is to be interrupted for a
time. Clear directions are a necessity for the dispenser to: (1) check
the proper dose for the patient; and, (2) enable effective patient
counseling.

11. Prescribers should avoid using vague dosing intervals such as

twice daily or hourly intervals like every 12 hours. These
 instructions can be seen as implicit rather than explicit and harmful
to patient understanding. Conversely, using precise dosing times
(e.g. 8 AM and 10 PM) may decrease patient adherence due to
individual lifestyle patterns, e.g. shiftwork. Write general times of
morning, afternoon, and evening to describe dosing intervals. 2

12. Personnel should transcribe verbal prescriptions in designated areas

that minimize interruption and distraction.

13. Practitioners should offer counseling to the patient about their

prescriptions. Counseling is often seen as the last attempt in
catching errors that occur in prescription writing. 3

14. All persons who prescribe medication have access to adequate and
appropriate patient information about the patient at the point of
prescribing including medical history, known allergies and their
reactions, diagnoses, list of current medications, prescription
monitoring program data, and treatment plan to assess the
appropriateness of prescribing the medication.

15. Conduct both initial and ongoing training of prescribers on

accepted standards of practice related to prescription writing
processes with the ultimate goal of risk identification and
medication error prevention.
Drug interaction
From Wikipedia, the free encyclopedia

(Redirected from Drug-drug interaction)

Certain medicines can interact pharmacologically and affect the activity of

other medicines.
A drug interaction is a situation in which a substance (usually another
drug) affects the activity of a drug when both are administered together.
This action can be synergistic (when the drug's effect is increased)
or antagonistic (when the drug's effect is decreased) or a new effect can be
produced that neither produces on its own. Typically, interactions between
drugs come to mind (drug-drug interaction). However, interactions may also
exist between drugs and foods (drug-food interactions), as well as drugs
and medicinal plants or herbs (drug-plant interactions). People
taking antidepressant drugs such as monoamine oxidase inhibitors should
not take food containing tyramine as hypertensive crisis may occur (an
example of a drug-food interaction). These interactions may occur out of
accidental misuse or due to lack of knowledge about the active
ingredients involved in the relevant substances.[1]
It is therefore easy to see the importance of these pharmacological
interactions in the practice of medicine. If a patient is taking two drugs and
one of them increases the effect of the other it is possible that
an overdose may occur. The interaction of the two drugs may also increase
the risk that side effects will occur. On the other hand, if the action of a drug
is reduced it may cease to have any therapeutic use because of under dosage.
Notwithstanding the above, on occasion these interactions may be sought in
order to obtain an improved therapeutic effect.[2] Examples of this include
the use of codeine with paracetamol to increase its analgesic effect. Or the
combination ofclavulanic acid with amoxicillin in order to overcome
bacterial resistance to the antibiotic. It should also be remembered that there
are interactions that, from a theoretical standpoint, may occur but in clinical
practice have no important repercussions.
The pharmaceutical interactions that are of special interest to the practice of
medicine are primarily those that have negative effects for an organism. The
risk that a pharmacological interaction will appear increases as a function of
the number of drugs administered to a patient at the same time.[3] Over a
third (36%) of older adults in the U.S. regularly use 5 or more medications
or supplements and 15% are potentially at risk for a major drug-drug
interaction.[4] Both the use of medications and subsequent adverse drug
interactions have increased significantly between 2005-2011.[4]
It is possible that an interaction will occur between a drug and another
substance present in the organism (i.e. foods or alcohol). Or in certain
specific situations a drug may even react with itself, such as occurs
with dehydration. In other situations, the interaction does not involve any
effect on the drug. In certain cases, the presence of a drug in an individual's
blood may affect certain types of laboratory analysis (analytical
interference).
It is also possible for interactions to occur outside an organism before
administration of the drugs has taken place. This can occur when two drugs
are mixed, for example, in asaline solution prior to intravenous injection.
Some classic examples of this type of interaction include
that thiopentone and suxamethonium should not be placed in the same
syringe and same is true for benzylpenicillin and heparin. These situations
will all be discussed under the same heading due to their conceptual
similarity.
Drug interactions may be the result of various processes. These processes
may include alterations in the pharmacokinetics of the drug, such as
alterations in the absorption, distribution, metabolism, and excretion
(ADME) of a drug. Alternatively, drug interactions may be the result of
the pharmacodynamic properties of the drug, e.g. the co-administration of
a receptor antagonist and an agonist for the same receptor.

The Five Rights of Medication Administration

by Frank Federico, RPh, Executive Director, Institute for Healthcare
Improvement
One of the recommendations to reduce medication errors and harm is to use
the five rights: the right patient, the right drug, the right dose, the right
route, and the right time. When a medication error does occur during the
administration of a medication, we are quick to blame the nurse and accuse
her/him of not completing the five rights. The five rights should be accepted
as a goal of the medication process not the be all and end all of
medication safety.
Judy Smetzer, Vice President of the Institute for Safe Medication Practices
(ISMP), writes, They are merely broadly stated goals, or desired outcomes,
of safe medication practices that offer no procedural guidance on how to
achieve these goals. Thus, simply holding healthcare practitioners
accountable for giving the right drug to the right patient in the right dose by
the right route at the right time fails miserably to ensure medication safety.
Adding a sixth, seventh, or eighth right (e.g., right reason, right drug
formulation, right line attachment) is not the answer, either. [The five
rights: A destination without a map. ISMP Medication Safety Alert. January
25, 2007;12(2).]

The five rights focus on individual performance and not on human factors
and system defects that may make completing the tasks difficult or
impossible.

There are a number of factors that may interfere with a nurses ability to
complete these functions.

Ms. Smetzer continues, Thus, the healthcare practitioners duty is not so

much to achieve the five rights, but to follow the procedural rules designed
by the organization to produce these outcomes. And if the procedural rules
cannot be followed because of system issues, healthcare practitioners also
have a duty to report the problem so it can be remedied.