“It’s important to write out medications that could be confused with the abbreviations of another medication, and avoid shorthand notations that can be confused with a number when it’s actually a letter,” Dr. Wright says.
Second, avoid trailing zeros. “If you want to give 10 ml of something, write it as 10 and spell out ml, not 10.0,” Dr. Basco says. “Don’t use unnecessary decimal places, especially when the order is faxed. A 10.0 could be read as 100 if the decimal point doesn’t come across clearly. That’s how you get a 10-fold dosing error.”
Additionally, the patient’s weight should be checked carefully and rechecked, especially when ordering riskier drugs, such as anti-coagulants and narcotics. “Our hospital pharmacy requires a weight on every drug order, so they can do calculations on whether the dose is appropriate,” Dr. Basco says. “They are requiring us to write down the drug that we want to deliver and its dose, as well as the milligram per kilogram per dose we want to deliver, so they can double check whether we’ve done our dosage calculation properly.”
Computers to the Rescue
More and more hospitals are moving toward electronic recordkeeping, including computerized physician order entry, also known as CPOE. “Although electronic records won’t eliminate errors, they tend to reduce them, especially when they include decision support,” Dr. Sachdeva says. “Decision support means that this is a ‘smart’ program that can look at the dose you ordered and tell you if the dose is correct based on the patient’s weight. It also scans the other medications that the person is on and make sure there are no allergies or potential drug interactions. Or, it can even disallow you ordering drugs that it knows will interact or know will cause allergies. The system won’t let you.”
For those hospitalists still required to write out orders, Randy Ferrance, DC, MD, a dual boarded internal medicine and pediatrics hospitalist at Riverside Tappahannock Hospital in Tappahannock, Va., says multiple checks and balances, from the time the drug is ordered to the time the patient receives the drug, are essential for reducing errors. “We write the order for the expected dosage per kilo and then the charge nurse checks our math, and then the pharmacist checks not only the math, but the expected dosage for the patient,” Dr. Ferrance says. Understanding the proper dosing range for specific drugs, he adds, is as crucial as is taking into account renal function.
Check with the Pharmacist
More hospitals are including pharmacists in their multi-disciplinary rounds, says Brian Bossard, MD, founder and director of Inpatient Physician Associates in Lincoln, Neb.
“We have a single pharmacist who works with each of our teams and functions as a liaison with the rest of the pharmacist staff in the hospital,” Dr. Bossard says. “This pharmacist reviews the medication list of each of our patients and focuses on patient safety initiatives, drug interactions and cost. The pharmacist writes up the verbal order after he talks to us, so there is no delay in getting the order on the chart. That, I think, goes a long way, in preventing drug-drug interactions that can lead to problems. Really, every day there are circumstances that are identified by the pharmacist that we change, so every day we’re seeing the benefits of this relationship.”